MANUAL FOR THE USE OF THE STETHOSCOPE. 

SHORT TREATISE 

ON THE 

DIFFERENT METHODS OF INVESTIGATING 
THE 

DISEASES OF THE CHEST. 

V 

TRANSLATED FROM THE FRENCH OF M. COLLIN. 

BY W. N. RYLAND, M. D. 

1 

FROM THE THIRD LONDON EDITION} WITH PLATES, 
AND AN 

EXPLANATORY INTRODUCTION, 

BY 
A FELLOW OF THE MASSACHUSETTS MEDICAL SOCIETY, 



Ham. Will you play upon this pipe ? 

Guil. My lord, I cannot — I have not the skill. — Shakspeare. 



BOSTON: 

BENJAMIN PERKINS & CO. 



1829/ 

L. 



1*1. 



I^t 



DISTRICT OF MASSACHUSETTS, to Wit: 

DISTRICT CLERK'S OFFICE. 

Be it remembered, that on the fifteenth day of December, A. D. 1828, 
in the fift}Mhird year of the Independence of the United States of Ameri- 
ca, Benjamin Perkins & Co. of the said district, have deposited in 
this office the title of a book, the right whereof they claim as proprie- 
tors, in the words following, to wit : 

u Manual for the use of the Stethoscope. A short treatise on the dif- 
ferent methods of investigating the diseases of the Chest. Translated 
from the French of M. Collin. By W. N. Ryland, M. D. From the 
third London edition ; with plates, and an explanatory introduction, by a 
Fellow of the Massachusetts Medical Society. 
Ham. Will you play upon this pipe? 
G-uiL My lord, I cannot — I have not the skill. — Shakspeare.^ 

In conformity to the Act of the Congress of the United States, entitled 
" An Act for the encouragement of learning, by securing the copies of 
maps, charts, and books, to the authors and proprietors of such copies, 
during the times therein mentioned ;" and also to an Act entitled " An 
Act supplementary to an Act, entitled an Act for the encouragement of 
learning, b}^ securing the copies of maps, charts, and books, to the au- 
thors and proprietors of such copies during the times therein mentioned j 
and extending the benefits thereof to the arts of designing, engraving, 
and etching, historical and other prints. 77 

JNO.W.DAVB, f C ^X^S'°' 



PRINTED BY FEIRCE AND WILLIAMS. 




ADVERTISEMENT. 

In preparing for the American press the English 
translation of the well known and highly useful work 
of M. Collin, which translation has passed through 
three editions in England, the editor thinks he can ren- 
der it more acceptable by dispensing with the various 
prefaces and introductory remarks which encumber 
the last edition ; and by substituting in their place an 
entirely new introduction, which is intended to em- 
brace the amount of all that is important in the prefaces 
alluded to, as well as that which is contained in various 
abstracts and reviews which have appeared of treatises 
upon the different methods of investigating thoracic 
diseases, and in some other works which are not gen- 
erally before the profession in this country. 



INTRODUCTION. 



Auscultation, or investigating diseases by the 
sound is, an ancient mode of diagnosis. It is treated of 
by Hippocrates, and is, withal, so simple an idea as must 
have been very obvious to all observers of disease. 
But mediate auscultation, that is, hearkening by means 
of an instrument, was first promulgated as a discovery 
hj M. L'aennec in his elaborate work, De V ausculta- 
tion Mediate, in 1819. Before this period, the only 
idea attached to auscultation as a means of diagnosis, 
was that of applying the ear as nearly as possible to 
the seat of the disease. The inconveniences of this 
method are sufficiently obvious, and from this cause, 
as well as the uncertainty of the signs to be derived 
from it, it had fallen into merited neglect. " I was 
consulted," says M. Laennec,*" "in 1816, by a young 
woman, who presented some general symptoms of dis- 
ease of the heart, in whose case the application of the 
hand and percussion gave but slight indications, on 
account of her corpulency. On account of the age 
and sex of the patient, the common modes of explo- 
ration being inapplicable, I was led to recollect a well 
known acoustic phenomenon, namely, if the ear be 
applied to one extremity of a beam, a person can, 

* Traite de 1'aus. med. torn 1. p. 7. 



VI INTRODUCTION. 

very distinctly, hear the scratching of a pin at the 
other end. I imagined this property of bodies might 
be made use of in the present case. I took a quire 
of paper which I rolled together as closely as possible, 
and applied one end to the precordial region ; by 
placing my ear at the other end, I was agreeably sur- 
prised at hearing the pulsation of the heart much 
more clearly and distinctly than I had ever been able 
to do by the immediate application of the ear. 

" I henceforward presumed this method might be- 
come very useful and applicable, not only to the study 
of the pulsation of the heart, but also to that of all 
those movements within the cavity of the chest, ac- 
companied by sound ; and consequently to the ex- 
ploration of the respiration, of the voice, of rattling, 
and perhaps even of the fluctuation of a fluid effused 
in the pleura or pericardium. 

" In this conviction, I commenced immediately at 
the hospital Neckar, a course of observations, which 
have resulted in the discovery of new 7 signs, sure, for 
the most part obvious, easy to be possessed of, and 
suitable to render the diagnosis of almost all diseases 
of the lungs, the pleuras, and the heart, more cer- 
tain, and perhaps more circumstantial, than even 
the surgical diagnostic signs established by the aid of 
the .probe or the finger." 

Medical experience, for the last ten years, has 
given abundant proof of the utility of the discovery of 
M. Laennec; and the discoverer has lived just long 




v 



INTRODUCTION. Vll 

enough to bring to perfection his method of diagnosis, 
to establish his own claims to the permanent gratitude 
of the profession, and to enrol his name high among 
medical philosophers. Although the Stethoscope is 
well thought of by most practitioners, yet it is intro- 
duced into practice by a very few only, and igno- 
rance, and prejudice, and perhaps in some instances, 
honest doubts have conspired to decry its use. But 
there never was a discovery of importance which had 
no objectors, and the negative testimony of all the rest 
of mankind, who do not apply the test of experiment, 
cannot outweigh the affirmative testimony of one com- 
petent witness who does do it. The Stethoscope has 
not wanted for admirers, and is as much in danger 
from indiscreet friends, as prejudiced opposers. It 
is at least so far received that a man may quietly 
use his Stethoscope as well as his stop-watch, and 
neither be called a quack or a conjurer, and if it be 
not so necessary to him as a telescope to the astrono- 
mer, or a compass to the mariner, yet if he will be at 
pains to carry it in his pocket and acquire a little readi- 
ness in its application, he may rest assured that he 
will obtain assistance in discriminating in many per- 
plexing cases of a class of diseases the most numer- 
ous and fatal of all those of a New England climate. 
" The actions going on in the chest are, the entrance 
and exit of the air in respiration, the voice, the mo- 
tion of the blood in the heart, and blood vessels ; and 
so perfectly do all these declare themselves to a per- 



Vlll INTRODUCTION. 

son listening through the Stethoscope, that an ear 
once familiar with the natural and healthy sounds, in- 
stantly detects certain deviations from them. Hence 
this instrument becomes a means of ascertaining 
diseases in the chest almost as effectual as if there 
were convenient windows for visual inspection ; and 
when it is considered that a fourth or fifth part of the 
inhabitants of Europe, die of diseases of the chest, 
such as inflammations, abscesses, consumptions, drop- 
sical collections, aneurisms, and various affections of 
the heart and blood vessels, which require an appro- 
priate treatment, the importance of such a means 
may be truly judged of."* 

The use of the Stethoscope has become familiar 
to many of the most enlightened and distinguished 
practitioners of Europe. In England it is ordered to 
be used generally by the army surgeons, who are re- 
quired to report their observations ; in this country it 
still remains a novelty. 

A correct diagnosis of thoracic diseases not only 
greatly involves the reputation of the practitioner, but 
in the highest degree, the safety and well-doing of the 
patient. The symptoms usually described as de- 
noting Hydrothorax, equally belong to certain forms 
of pneumonia ; and what can be more widely differ- 
ent than the appropriate treatment of those two dis- 
eases ? It has been statedf " that no practical er- 

* Arnott's Elements of Physics, 2d edition, p. 488-9. 
t Dr. Groves' and Dr. Stokes' Medical Cases, in Meath Hos- 
pital. Dublin Hosp. Rep. vol. 4. , 



INTRODUCTION. IX 

ror is of more frequent occurrence than the attributing 
to Hydrothorax, symptoms which belong to pneumo- 
nia. Numerous cases have been sent into the me- 
dical wards of the Meath Hospital, by practitioners 
who had named and treated them as cases of simple 
Hydrothorax ; but in no instance have we found this 
diagnosis correct, and more than once have we suc- 
ceeded in saving the life of such a patient, by the bold 
use of the lancet, at a period of the disease when a 
reliance on antidropsical remedies alone would have 
been of no avail." But the case, the most common 
to the New England practitioner, which calls for ad- 
ditional means of discrimination, is that of diseases 
simulating pulmonary consumption, the scourge of our 
northern climate. We are called upon by an anxious 
sufferer to tell him if his disease admit of a remedy, 
or must be borne without hope. With what indus- 
try and perseverance then, should we educate our 
senses to the use of those methods of investigation, 
laborious and difficult though they be, which promise to 
enable us satisfactorily to resolve such a question. 

The following case, taken from a modern work,"* 
is the best answer to one who asks what good is to be 
derived from the diagnosis of consumptive diseases. 
" M. Laennec was consulted, in the case of a gentle- 
man, who was supposed to be dying from Phthisis 
Pulmonalis, and in a state so desperate that he was 

* Observations on M. Laennec's Method, &c, &c, by Charles 
Scudamore,M.D. F. R. S. 1836, 



X INTRODUCTION. 

not expected by his medical attendant to survive 
more than two or three days. M. Laennec made his 
usual investigation, and persuaded himself that the 
case had been mistaken, and that the alarming symp- 
toms did not arise from ulceration of the lungs, but 
from empyema or purulent collection within the pleura. 
He strongly recommended that the operation for this 
disease should be performed ; and after a little hesi- 
tation and delay, his advice was adopted. A large 
quantity of pus was evacuated, and immediate relief 
was afforded. The amendment was rapid, and the 
progress of cure so favorable, that the gentleman re- 
covered his health in less than three months." It is 
especially desirable in the diseases of the chest of in- 
fants, who cannot communicate their sensations by 
words, that we should employ those means which may 
make their symptoms obvious to our senses without 
the aid of language. Auscultation, therefore, may be 
looked upon as a most desirable mean of investiga- 
ting these diseases. 

Percussion and auscultation are intimately con- 
nected, and should be studied and practised together. 
Corvisart was the first to introduce into general notice 
the employment of percussion, by his translation and 
notice, in 1808, of the writings of Leopold Avenbrug- 
ger, a native of Graets in Styria, published in 1761. 
This operation consists in striking upon the walls of 
the thorax, and the sound returned wall of course be 
modified by the state of the viscera of this cavity, so 



INTRODUCTION. XI 

that to a person accustomed to the sounds afforded 
by percussion of the thorax in a state of health, the 
deviations produced by disease will be sufficiently ob- 
vious. The sound is obtained with more distinct- 
ness, when the lungs are most distended with air, as 
during inspiration. The best mode of performing 
percussion is to place the ivory cup, which is annex- 
ed to the end of the most approved form of Stetho- 
scope, flat upon the part, and apply a light quick 
stroke of the fore and middle finger. Every part of 
the chest may thus be examined, directing the patient 
to draw in his breath, and retain it while you apply 
the stroke of percussion. The advantage of the cup 
is, that you occasion less pain and fix with more cer- 
tainty the exact spot which yields any unnatural sound. 
The Stethoscope, as it was first used by Laennec, 
hardly needs a description. It is a simple cylinder 
of wood perforated in the middle, and used sometimes 
with a funnel shaped extremity, and sometimes with- 
out it; the change being made by putting in or taking 
out a conical plug, at the end of the instrument which 
is applied to the chest. It should be made of some 
fine grained, light wood, such as cedar or maple. The 
plate at the end of the volume, sufficiently explains 
the common form of the instrument ; the principal ob- 
jection to which is, that it is too large to be a conven- 
ient inmate of the coat pocket. A more portable in- 
strument is one which the editor has found to answer 
all the purposes of Laennec's first Stethoscope, and is 



Xll INTRODUCTION. 

little more than half as long, and instead of being cyl- 
indrical, is trumpet shaped, with a circular rim, or 
ear piece, to be screwed upon the small end, when 
the instrument is used. It has also affixed to it a 
plate of ivory, which is the pleximeter of M. Piorri, 
(mentioned page 19) and is employed to prevent the 
pain of the stroke in percussion.* As is to be ex- 
pected the ear must undergo tuition in practising with 
the Stethoscope, and the natural phenomena must be 
studied with great care before the morbid alterations 
can be perceived. A beginner should, therefore, not 
give up in despair, because his first trials are abortive. 
A very skilful observer has asserted that it required 
two days study for him to perceive the murmur of re- 
spiration, one of the most obvious of the healthy phe- 
nomena. 

In exploring the movements of the heart there 
are several circumstances which give a great value 
to the signs derived from auscultation. It is obvious 
that all the knowledge we obtain from the examina- 
tion of the pulse at the wrist, is merely as to the mode 
of action of the left ventricle of the heart, and that in 
diseases of the heart, the practical value of auscultation, 
which informs us of the movements of both ventricles 
and both auricles, must be greatly before that of the ex- 
amination of the pulse at the w r rist. For it is pathogno- 
mic of some affections, that the action of the heart, and 

* This form of the Stethoscope may be obtained at the pub- 
lishers. 



INTRODUCTION. Xlll 

the fulness and strength of the pulse, are in inverse 
proportion to each other. 

It has been proposed to use the Stethoscope for the 
diagnosis of other diseases than those of the thoracic 
contents. Laennec proposes its use in investigating 
the diseases of animals, and Lisfranc has applied it 
with success to distinguish the crepitus of fractured 
bones. May it not be resorted to with advantage to 
ascertain the force of the heart's contraction in cases 
of severe flooding, and thus assist in deciding upon 
the disputed question of transfusion ? The editor 
has witnessed a case in which, at a period of danger- 
ous exhaustion from this cause, the heart's impulse, as 
perceived by the Stethoscope, was unexpectedly 
strong and distinct, and essentially contributed to in- 
spire confidence in a favorable prognosis. 

The following are rules useful to be observed in the 
management of the Stethoscope. 

1. To procure stillness in the room in which the 
patient is placed, although to long practised ausculta- 
tors, this precaution is in part unnecessary. Laennec 
repeatedly asserted that his organ of hearing was so 
adjusted to distinguish minute difference of sound, 
that he could, at. the same time, observe the move- 
ments of the heart — the noises produced during re- 
spiration by air, mucus, &c. in the lungs, and in the 
stomach and intestines ; the noise of his own, and the 
patient's movements ; and all this, while his students 
were moving and whispering round him. 



XIV INTRODUCTION. 

2. The Stethoscope is to be used without the stop- 
per, in exploring the phenomena of respiration, and 
the different rattles ; and with it, to examine the cir- 
culation, and the voice. 

3. It is not necessary that the part to which the 
Stethoscope is applied should be uncovered, but only 
that the covering be not too thick, be perfectly 
smooth, and not of a kind to produce a rustling noise, 
as silk or worsted will do. 

4. The instrument must be applied perpendicu- 
larly, and so retained on the chest as to fit and press 
equally on every part, and at the same time the ear 
should be applied to the other extremity so as to ex- 
clude the external air, the hole of the cylinder being 
opposite the meatus auditorius. 

5. In examining the respiration, the patient should 
be directed to respire a little more rapidly than natural, 
without creating a sound more audible than usual at 
a distance. In examining the voice, he may count 
aloud, slowly, in a natural tone of voice; and for ex- 
ploring the different rattles, the patient should be di- 
rected to cough occasionally. 

6. The observer should be careful not to place him- 
self in a constrained position, and for this purpose it 
is often convenient to rest upon one knee. 

Salem, Nov. 1, 1828. 



CONTENTS. 



PART I. 

Chapter i. 

Page 

Examination of the movements of the Chest in Respiration, - 1 

Respiration in Health, ------- 2 

in Disease, --3 

Chap. ii. 

Of Percussion, -- 13 

in Health, 14 

in Disease, ------- 19 

New Method of Percussion, 19 

Chap. hi. 

Of Auscultation, 23 

Natural Phenomena furnished by the Respiration, 28 

by the Voice, - 31 

by the Heart, - 33 

Pathologic Phenomena, ------- 38 

furnished by the Respiration, 38 

■ — by the Voice, - 47 

. by the Heart, - 64 

Of Mensuration, - 77 

Of Succussion, - - - 81 



XV CONTENTS. 

PART II. 
Chapter i. 

Of Diseases of the Pleura and Lung - , 83 

Comparative value of the various modes of examination, - 83 

Of Pleurodynia, 87 

— Pulmonary Catarrh, - 88 

— Pulmonary Apoplexy, 90 

— CEdema of the Lung, 91 

— Emphysema of the Lung, 92 

— Pneumonia, 95 

— Empyema and Hydrothorax, ------ 101 

— Pleurisy, 101 

— Pulmonary Phthisis, 106 

— Gangrene of the Lung, 110 

— Pneumo-thorax, Ill 

Chap. ii. 

On the Diseases of the Heart, 114 

Diseases characterized by the alteration of the shock, - - 124- 

Hypertrophy, 124 

Hypertrophy of the left Ventricle, 125 

right ventricle, 1 2.3 

Disease characterized by alteration of the Sound, - - - 126 

Dilatation of the Heart, 126 

Diseases characterized by alteration of impulse and sound, - 127 

Dilatation with Hypertrophy, 127 

Contraction of the Orifices of the Heart, - - - 128 

Softening of the Heart, 1£8 

Aneurism of the Aorta, 129 

On the use of the Stethoscope in Internal Aneurism, - - 130 

In Pericarditis, and Hydropericardium, 131 



A 

TREATISE, 

&c. fa. 

PART L— CHAP. I. 

Examination of the Movements of the Chest 
in Respiration. 

Respiration, like digestion, is a function, 
which, according to the ingenious idea of 
Professor Chaussier, requires the taking in of 
a foreign substance, by the action of volun- 
tary* muscles ; it is divided into two acts, 
inspiration and expiration. 

Inspiration is the movement by which the 
thorax, separating its walls, augments its in- 
terior capacity, allowing the air to enter into 

* Though correctly translated, the statement ap- 
pears erroneous ; the muscles of respiration, although 
sometimes aided by voluntary efforts, performing their 
office independently of the will, as in sleep, &,c. 



2 STATE OF RESPIRATION IN 

the lungs : expiration is the return of the 
walls to their former state. 

These movements are always free and easy, 
so long as no obstacle exists to their perfect 
exercise ; an affection of the lung, or of the 
cavity which contains it, will always induce 
an alteration, generally to be recognized with- 
out difficulty. These alterations must be 
known, but it is first better to give an idea 
of respiration in the healthy state. 

SECTION I. 

In a healthy man, unagitated by passion, 
inspiration and expiration should be perform- 
ed slowly, without violence and without any 
muscle seeming to make a painful effort to 
produce them : they succeed each other with 
regularity : their rhythm is constant and uni- 
form ; all the ribs rise, and dilatation and 
contraction are equally marked on each side, 
except in case of deformity of the thorax. 

The succession of the movements is more 
or less rapid in different individuals ; in 
general there are from fifteen to twenty 
respirations in a minute, and of each five 



DISEASES OF THE CHEST. 3 

respirations, one is observed to be stronger 
than the others. 

In children, women, and weak individuals, 
the frequency of respiration is greater. The 
passions, exertion, or repose, the will, the 
qualities of the air, cause a variation in it 
every instant ; during sleep it is slower and 
deeper. 

Respiration may be effected by the inter- 
costal and other inspiratory muscles, and is 
then thoracic, or it may take place by the 
action of the diaphragm alone, and is then 
said to be abdominal. Some authors affirm, 
that during the waking state, it is the dia- 
phragm which contributes most powerfully to 
this act, and the intercostals during sleep. 

SECTION II. 

In disease, the movements of the thorax 
may offer many varieties, which we shall re- 
late in the following divisions. They may 
be either frequent or rare, quick or slow, 
regular, or irregular, great or small, equal or 
unequal, easy or difficult, complete or in- 
complete ; finally, respiration may be either 
abdominal or entirely thoracic. 



4 PECULIARITIES OF RESPIRATION 

To observe these different alterations well, 
the patient should be made to sit, if his 
strength will allow of it, in order that no- 
thing may obstruct the muscular motions 
which assist respiration ; the arms should 
hang freely and the thorax should be un- 
covered ; but usually these precautions are 
not required. 

1st. Considered relatively to the number 
of inspirations and expirations in a given 
time, respiration is frequent ox rare; frequent, 
when, in an adult, more than eighteen or 
twenty respirations occur in a minute ; rare, 
when a less number occur. 

This frequency is natural to children, to 
women, and persons of a sanguine tempera- 
ment ; in warm climates ; in summer, when 
the air being more rarefied contains less oxy- 
gen in a given quantity ; and after exercise, 
or great emotion. 

It also occurs independent of all thoracic 
affection, in verminous complaints, in the 
spasmodic, and all the pyrexial diseases. 

The respiration is usually observed to be 
rare only in soporose and hysteric affections, 
and the latter moments of life. 



IN DISEASES OF THE CHEST. 5 

A pain in the thorax ; an obstacle to the 
free passage of the air through the bronchia ; !r 
every alteration which renders a part of the 
pulmonary tissue unfit for respiration, are the A 
causes of increase of frequency ; suspension of 
the nervous influence, debility of the muscular 
powers, are the causes of increased rarity. 

2d. Respiration may be quick or slow. It 
is quick when the movements of inspiration 
are short, rapid, and abrupt ; slow, when they 
are long and gradual. Quick respiration is m 
usually united with frequent respiration ; it is 
then termed accelerated ; this may be carried 
to panting. 

Quick respiration is sometimes combined 
with the rare in robust subjects, in acute 
diseases, and in the latter moments of life. 
Vivacity of respiration appears to depend on 
the same causes as its frequency. Its slow- 
ness is observed in the same circumstances as 
its rarity, which it often accompanies and 
depends on the same lesion. 

3d. When the inspirations and expirations 
follow each other at equal intervals, respira- 
tion is said to be regular ; it is irregular when 
these intervals are more or less prolonged in 
*2 



b PECULIARITIES OF RESPIRATION IN 

relation to each other ; intermittent, when one 
or more inspirations supervene late or not at 
all ; interrupted, when the expiration seems 
to take place before the inspiration is finished. 

These different modifications occur in the 
phlegmasiae of the thoracic and abdominal cav- 
ities, and particularly in nervous affections. 
The causes above enumerated may produce 
them. 

4th. Respiration is said to be great in those 
cases in which an inspiration, either slow or 
quick, attended with a full expansion of the 
thorax, succeeds an entire perfect expiration. 
It is small, when the dilatation is scarcely 
sensible. 

We thus see that the respiration is not large 
when the thorax remains expanded, the in- 
spiration not being followed by a full expira- 
tion. So in peripneumony, the respiration is 
frequent, quick, and small, although the chest 
is completely expanded ; this is called a high 
respiration. 

The large and rare respiration constitutes 
the sublime ; it rarely accompanies affections 
of the air passages ; it is more usual in cere- 
bral fevers, on the approach of phrenitic de- 
lirium. 



DISEASES OF THE CHEST. 7 

The smallness of the respiration is more 
usually indicative of thoracic affection, or 
lesion of the thoracic parenchyma, 

M. Landre Beauvais has called that respi- 
ration great or large, in which much air is 
inspired, and that small in which little is taken 
in. As I examine the respiration in relation 
to the movements of the chest, I have con- 
sidered it necessary to give the same name to 
a different phenomenon, but one which fre- 
quently coexists with that noted by this 
learned professor. 

5th. Respiration is equal, when inspiration, 
whether great or small, quick or slow, is fol- 
lowed by a similar expiration ; unequal, when 
one or other of these movements is stronger 
or more prolonged. Adynamic and ataxic 
fevers, most spasmodic affections and asth- 
mas, offer examples of it. This inequality 
is a constant symptom of pleurisy and acute 
pneumonia. When the pleura is inflamed, 
inspiration is quick ; expiration, although 
short, appears long as compared to inspira- 
tion ; the seat of the pain in this complaint 
easily accounts for this phenomenon. 



8 PECULIARITIES OF RESPIRATION 

When the phlegmacy occupies the lung, it 
is the expiration, on the contrary, which pre- 
sents this brevity, the affected organ being by 
this painfully compressed : in this case the 
thorax seems always raised. 

The high respiration, which we have al- 
ready said to be a symptom of this affection, 
depends on the difficulty of expiration. 

6th. Respiration is said to be easy, when 
the muscles destined to produce expiration 
(inspiration ?) are sufficient, and execute this 
movement without difficulty ; it is difficult, 
when the large accessory muscles are called 
into action, or, when the properly inspira- 
tory muscles contract with violence, or as if 
convulsively. Simply inspecting the neck, 
enables us to recognize this difficulty of 
respiration ; the hard projecting scaleni, im- 
press shocks on the lateral parts of the 
neck, easily distinguished. The intercostals 
exhibit the same in thin persons. This state 
has different degrees : thus the respiration 
may be simply difficult or laborious, or it may 
be suffocating. 

In the last case, the patient threatened 
with suffocation cannot keep the horizontal 



IN DISEASES OF THE CHEST. V 

posture ; sitting and bending forwards, he 
forcibly presses his head upon his raised, 
knees, seeking a firm support for the hands, 
and thus fixing the upper extremities, forcibly 
contracts the muscles of respiration, of which 
every effort is concentred on the thorax to 
to dilate it fully. 

To this variety of respiration the name of 
orthopnea has been given ; it is common in 
paroxisms of asthma, and becomes sometimes 
habitual in persons affected with emphysema 
of the lungs. The convulsive respiration, a 
common symptom in the different diseases 
comprehended under the term asthma, may 
be referred to difficult respiration. M. Pas- 
cali has lately communicated to the Academy 
of Medicine observations upon the employ- 
ment and utility of galvanism in those cases. 
It would appear from his experiments, that 
this convulsive state of the respiration, de- 
pends rather on an alteration of the vital 
powers of the nervous system, distributed to 
the muscles of the thorax, than on that of 
the lung itself. 

The chief part of the thoracic and a great 
number of abdominal diseases, render the 



10 PECULIARITIES OF RESPIRATION 

respiration difficult. Thus every obstacle to 
the entrance of air into the lung, or to the 
dilatation of the thorax, whether existing in 
the cavity or not, may induce difficulty of 
respiration. 

7th. I call that respiration complete in 
which the lungs of both sides concur equally ; 
it is characterized by equality of force and 
extent in the movements of the thorax. I 
call that incomplete, in which one side remains 
wholly or in part immoveable, or moves less 
than the opposite one. 

This sign is among the most certain and 
constant of all those furnished by the exam- 
ination of the movements ; it belongs almost 
exclusively to diseases of the organs of this 
cavity : it is sometimes sufficient to point out 
pleurisy or peripneumony in infants ; it will 
enable us in all cases to dispense with the 
tedious questions, and fatiguing and useless 
researches, by pointing out the seat of the 
disease. 

It depends at one time on a phlegmacy of 
the lungs, at another on an effusion ; a simple 
pleurodyne may also produce it. It is not 
rare to meet individuals who present it al- 



IN DISEASES OF THE CHEST. 11 

though enjoining perfect health, but it is then 
the result of preceding disease, which has pro- 
duced numerous and close adhesions between 
the coats of the pleura. It may depend perhaps 
as much on the tissue of the lung being imper- 
meable to the air, as on those adhesions. 

8th. We have mentioned that variety of re- 
spiration, of which the term abdominal alone 
gives an idea. The belly rises in inspiration, 
sinks in expiration, and the ribs execute no 
movement. 

This phenomenon is observed when both 
sides of the lungs are become unfitted for 
respiration ; it is among the worst symptoms, 
and is usually a forerunner of death. How- 
ever, the respiration becomes naturally ab- 
dominal in very old persons, owing to the 
ossification of the cartilages of the ribs, 
which opposes the action of their muscles, 
already weakened by age. 

9th. Thoracic respiration, effected by the 
elevation of the ribs, without the assistance 
of the diaphragm, is observed in all cases of 
intense extensive inflammation of the abdo- 
minal organs, or when this cavity is distended 
by the produce of conception, or other acci- 
dental production. 



12 PECULIARITIES OF RESPIRATION. 

Such are the changes that take place in the 
movements of the thorax in relation to their 
rhythm, their extent, facility, and simultane- 
ousness. 

The other modifications of the respiration 
relate to the qualities of the air expired, or 
to the noise it produces, either in entering the 
thorax, or escaping from it. We shall speak 
of them elsewhere. • ' 



CHAP. II. 

Of Percussion. 



SECTION I. 

This mode of investigation, proposed by 
Avenbrugger, and brought to perfection by 
Corvisart, was for a long time the only one 
in practice, and with experienced practition- 
ers contributed much to the certainty of 
diagnosis in diseases of the chest. Since 
the discovery of auscultation, it has lost none 
of its advantages ; and it would be an error 
to suppose that the assistance of the stetho- 
scope renders its use unnecessary. 

The cavity of the thorax, which in the 
healthy state is almost entirely filled by the 
lungs, and always more or less distended by 
air, returns a sound when struck, very simi- 
lar to that of an empty barrel. (This com- 
parison, though inexact, is the most correct 
3 



14 OF PERCUSSION IN 

I have been able to find.) The word percus- 
sion has been applied to the means employed 
to ascertain the nature of this sound. 

The sound returned by the chest when 
struck upon, is always proportioned to the 
capacity of this cavity, and to the thickness 
and elasticity of its walls, but has not the 
same character at all points. It varies, 1st, 
According as the part is covered by thick and 
fleshy integuments ; 2d, According to the 
degree of leanness, of fatness, or of infiltra- 
tion* of the subject ; 3d, According to the 
posture of the patient ; 4th, According to 
the manner in which percussion is practised. 
All these varieties should be well known 
in a healthy subject, to enable us to appre- 
ciate the changes arising from disease. 

1st. According to the Points of the Chest 
struck upon. A clear sound is obtained when- 
ever we strike upon a bony part covered by 
the skin only, or by thin muscles sufficiently 
stretched to transmit the shock wholly, with- 
out absorbing any of the sound. The most 

* The anasarcous state of the integuments of the 
chest. 



DISEASES OF THE CHEST. 15 

favorable parts are, anteriorly, the clavicles, 
when they are not too much elevated and 
raised from the thorax ; the space lying two or 
three inches below them ; all the surface of 
the sternum, and the parts nearest the carti- 
lages of the ribs. 

In the remaining anterior part of the tho- 
rax, the mamma in females, the fat which 
covers over the middle and inferior part of 
the pectoralis major in many men, the vicinity 
of the liver on the right, and of the heart on 
the left, diminish the sonorousness natural to 
the thorax. 

Upon the sides we may strike with advan- 
tage, in the hollow of the axilla, and three 
inches below it ; but from the fourth and 
sometimes the third rib downwards, the sound 
is always less clear on the right, owing to the 
neighborhood of the liver ; while on the left, 
it is often louder than it ought to be from the 
proximity of the stomach, particularly when 
that viscus is much distended by air ; the 
resonance then becomes something metallic. 

Behind, the most distinct sound is perceiv- 
ed along the costal angles. In thin persons 
we may percuss usefully on the supra and 
infraspinal hollows of the scapulae, and upon 



16 OF PERCUSSION IN 

the spine of that bone, but we cause no sound 
in striking upon the fleshy layer of muscles 
which fills up the vertebral hollows. 

2d. According to the Leanness, Fatness, or 
Infiltration of the Subject. It is evident that, 
all other things being equal, the chest will be 
more sonorous in thin subjects than in those 
overburdened with fat, and that it will return 
no sound in patients the parietes of whose 
thorax are anasarcous. 

3d. According to the Posture of the Patient. 
The more the thorax is separated from all 
around, the less will the sound be altered ; 
we should not then percuss when the chest 
is covered with clothes, or sunk in a soft bed 
or pillows. 

When we examine the anterior part, the 
patient should be seated with his arms carri- 
ed backwards. He should raise them above 
his head when his sides are examined, and 
cross them over his breast, at the same time 
arching his back, while we examine that part. 
These different positions stretch the muscles 
which cover the thorax. It is not always pos- 
sible to place patients in those positions : 
when such is the case we make them lie flat 



DISEASES OF THE CHEST. 17 

upon the back, and raise the arms over the 
head, while we examine the lateral and ante- 
rior parts of the thorax ; but the results thus 
obtained are always less striking and less 
certain. According to M. Laennec, the 
smallness of the alcove, and the narrowness 
of the chamber, alter the quality of the 
sound. 

4th. According to the mode of performing 
Percussion. This operation, apparently so 
simple, requires a number of precautions to 
be truly useful. We shall point out the best 
manner of proceeding. 

We should close and bring together all the 
ends of the fingers half bent, or we should 
form them upon the same line, so that one 
may not project beyond the other. We 
should then strike with an equal and moderate 
force upon similar parts, in the same direction 
and extent, making the ends of the fingers 
fall perpendicularly to the plane upon which 
we strike. 

Too strong percussion would be painful ; 

an unequal one would give an unsatisfactory 

result. It would be the same if we struck 

dissimilar parts, as a rib and an intercostal 

*3 



18 OF PERCUSSION IN 

space ; if the fingers inclined perpendicularly 
on the right, obliquely on the left side ; on a 
space double or triple the extent on one side 
to the other, since each of these variations 
must necessarily modify the sound. It is also 
necessary not to examine all the points of one 
side before passing to the other, because we 
thus lose the remembrance of the results ob- 
tained in corresponding points ; it is better to 
strike first on one side, and then on the other. 

To fulfil all these conditions, none of which 
are superfluous, we must strike as much as 
possible with the same hand, and place it in 
the same direction relatively to the part 
struck. 

Percussion with the hand extended has 
sometimes advantages, whether we wish to 
know the sound of a great part of the thorax, 
or to ascertain that the walls of this cavity 
are too thick to answer otherwise. But we 
must not let the air confined between the 
hand and the thorax, produce a sound capa- 
ble of masking that of the thorax itself. 
Further, we should leave the hand applied 
to the thorax to feel if the trembling motion 
resulting from the elasticity of the lungs ex- 



DISEASES OF THE CHEST. 19 

ists, or has ceased to be produced. Slight 
blows with a stethoscope, or other solid body 
of convenient form, are often the best means 
of producing appreciable sounds.* 

SECTION II. 

In the state of disease, the sound returned 
by the thorax is often altered. These alte- 
rations are four in number. The sound may 
be dull, obscure, absent, or more clear than 
natural. The names point out the nature of 
these alterations ; it remains only to explain 
their causes. 

* A new method of percussion has lately been pro- 
posed by M. Piorri, which consists in making the per- 
cussion upon a circular piece of wood or ivory, a line 
in thickness and an inch and a half in diameter, with 
a small handle to keep it in its place. The advanta- 
ges of this method are said to be, that by it we obtain a 
louder sound, insomuch as the operation may be per- 
formed through the clothes; that we can employ a 
greater force, and employ a more sonorous body than 
the fingers; that we can select more accurately the 
point to be percussed, and protect the parts better from 
the effects of the blow. 

Some persons use the stethoscope as a hammer in 
making percussion ; but it is ill adapted for this use, 
and is apt to bruise the parts struck. 



20 OF PERCUSSION IN 

Every time the lung loses its elasticity and 
becomes engorged, without however becom- 
ing totally impermeable, the sound becomes 
dull or obscure, according as the engorging of 
the pulmonary tissue is more or less consider- 
able. Thus then an intense catarrh*, the 
first degree of pneumonia, an oedema of the 
lung, produce this alteration. 

The sound becomes wanting in two cases ; 
1st. When the lung loses its permeability 
completely, its tissue becoming dense, like 
the substance of the liver, in consequence of 
an abundant exhalation of blood into its 
areolae, and of the combination of this liq- 
uid with its tissue. 2d. When it is compres- 
sed, thrust back by some accidental produc- 
tion, developed in its thickness, or in the cav- 
ity of the pleura, or when this cavity is filled 
by some fluid. 

In either case, a greater or less part of the 
side affected may be yet sonorous, according 
as the hepatization, the accidental tumor, 
or the effusion, are more or less considerable. 
Finally, the sound will acquire a greater in- 

* Catarrh has the same meaning in France, as Bron- 
chitis in England. — Transl. 



OF PERCUSSION IN. 21 

tensity than in the natural state, when the 
pulmonary tissue becomes as it were rarefied, 
or when the cavity of the pleura is occupied 
by air, or other gaseous body* 

If I have not spoken of percussion upon the 
precordial region, in cases of disease of the 
heart, it is because it is rare to meet cases of 
hypertrophy considerable enough to deter- 
mine perfect dulness of sound ; and that in 
cases where the sound is simply obscure, we 
can conclude nothing from it, from inability 
to establish a comparison between this part 
and that of the opposite side. This remark is 
correct, if we have yet had no opportunity of 
seeing and percussing the patient ; but if we 
can compare his present with his former state, 
and thence observe some difference in sono- 
rousness percussion then offers valuable signs, 
very useful in the diagnosis. 

The signs furnished by percussion are of 
great importance ; w r e must not however de- 
pend on them always ; it may happen that the 
sonorousness of the chest may be altered by 
causes foreign to the organs of the cavity. 
Thus every large tumor in the abdomen, 
pregnancy, ascites, diminish the sonorousness. 



22 DISEASES OF THE CHEST. 

and contract the thoracic cavity, thrusting up 
the lungs ; but no cause, entirely indepen- 
dent of the pectoral organs, can produce a 
complete loss of sound. 



CHAP. III. 

Of Auscultation. 



The word auscultation is applied to the 
examination, by means of the ear, of the dif- 
ferent sounds produced in the interior of the 
thoracic cavity, by the circulation of the aif, 
the resounding of the voice, or the palpitation 
of the heart. It is either mediate or imme- 
diate. 

Immediate auscultation, is that in which 
the ear is applied naked to the different 
points of the chest. Inconvenient and disa- 
greeable to the patient, it is besides far from 
giving the results that it seems to promise. 
The sounds it yields, have never a perfect 
clearness ; transmitted through the whole 
surface of the head, which is in contact with 
the breast, they have too much force to allow 
us to appreciate justly their shades, and they 
are all so confounded, that it is difficult to 



24 OF AUSCULTATION IN 

distinguish the parts from which they pro- 
ceed. 

It is difficult, besides, for the head to fol- 
low the different movements of rising and 
falling of the chest ; and the friction of the 
clothes adds still to confusion. 

In fine, although it may be good in some 
cases, it is not applicable to all ; the ear can- 
not be placed upon all parts of the thorax, 
particularly in women, with whom decency 
alone would suffice to prohibit this mode. 

The inconveniences which have prevented 
us from having recourse to this method, and 
which have retarded the discovery of a means, 
simple and easy in its execution, and which 
M. Laennec has demonstrated to be so fruit- 
ful in the results, so advantageous, I may say 
so necessary in the practice of physic, are 
without doubt numerous. 

If this learned professor was indebted to a 
happy chance for his first ideas of it, he soon 
recognised the immense advantages this 
means might procure ; he anticipated its im- 
portance, its utility. To invent an instru- 
ment, proceed to a long series of researches, 
collect numerous observations in minute de- 



DISEASES OF THE CHEST. 25 

tail, verify by inspections the diagnosis for- 
med at the patient's bed-side, arrange facts, 
seek the most probable explanation of the 
phenomena daily presenting themselves, pub- 
lish a work to which the repeated experiments 
of the numerous partisans of his method can 
scarcely add a few pages, — was to him a labor 
of only three years. 

I shall not here describe the stethoscope : * 
it is too well known to require a particular 
detail. It is sufficient to say, that M. Laen- 
nec has determined by numerous experiments, 
that the cylindric form is best ; that it is ne- 
cessary to make use of wood, neither too light 
nor too dense, in the formation of the cylin- 
der ; that it should be a foot long, fifteen lines 
in diameter, and its canal three lines ; that 
one of its ends should be hollowed out in a 
conical form, and have a stopper adapted to it 
to be used when necessary. 

To make use of the stethoscope, it should 
be held as a writing pen, the ends of the fin- 
gers closed upon the instrument, so as to feel 

* From <rry,&o<r pectus and o-xosrla speculor, the chest- 
inspector. — Ed. 

4 



26 OF AUSCULTATION IN 

at once the end of the cylinder and the point 
of the chest upon which it is rested ; the end 
of the instrument should be placed flat upon 
this part, so that it may be perfectly perpen- 
dicular ; and where excessive emaciation ren- 
ders the intercostal spaces hollow and the 
ribs projecting, the concavity should be filled 
up by charpee *, or other soft substance f . 

The ear should rest more or less forcibly 
upon the other end of the instrument ; use 
will teach the cases in which it is to be 
applied lightly, and those requiring a cer- 
tain degree of pressure. 

We must remove some of the patient's 
clothing if the part be too thickly covered, or 
if the clothes be made of wool or silk, or oth- 
er stuffs capable of causing a sound resem- 
bling those heard with the cylinder. In the 
examination of the respiration in particular, 
we must not judge from the first moments of 
the investigation ; the buzzing arising from 

* Charpee, linen separated into threads, instead of 
being scraped into lint, as with us. It is used for the 
same purposes as lint. 

t Cotton wool is a good and convenient material for 
this purpose. 



DISEASES OF THE CHEST. 27 

the application of the instrument ; the fear, 
the constraint, the embarrassment of the pa- 
tient; the palpitations of the heart, render 
the sounds obscure, and hinder us from dis- 
tinguishing them accurately. 

In exploring the palpitations of the heart, 
and the phenomena produced by the voice, 
the cylinder is to be used with the stopper 
in ; but without it, when we wish to hear the 
noise of respiration, or the sounds of which 
the heart is sometimes the seat. It may be 
applied with the same facility upon all parts 
of the chest. The phenomena this examina- 
tion makes known, are natural or pathologic. 
The natural phenomena are those which exist 
in the sound state of the organs ; they must 
be studied first, in order not to confound them 
with those produced by disease, and to ena- 
ble us to note their absence and appreciate 
clearly their alterations. 

SECTION I. 

Natural Phenomena. 

These differ according as they are produced 
by the respiration, the voice, or the heart. 



28 OF AUSCULTATION IN 

They form therefore three classes, each of 
which shall be the object of a separate article. 

* Art. I. — Natural Phenomena furnished by 
the Respiration. 

They offer some variety : 1st, According to 
the points examined ; 2d, The frequency of 
the respiration ; 3d, The age, sex and partic- 
ular disposition of the individuals examined. 

1st. According to the points examined. 
On applying the cylinder to the thorax of a 
healthy man, we hear, at every inspiration 
and expiration, a gentle but very distinct 
noise, which indicates the penetration of the 
air into the pulmonary tissue, and its expul- 
sion from it. It may also be perceived 
clearly that the air is received into a series of 
very small cavities, which expand to admit 
it, and not into one large extensive cavity. 

This murmur is nearly equally strong in all 
points of the chest, but most so in those at 
which the lung is nearest to the surface of the 
skin, that is, at the superior lateral and the 
posterior inferior parts. The hollow of 
the axilla, and the space between the clavicle 
and edge of the trapezius, are the points 
where it has most intensity. 



DISEASES OF THE CHEST. 29 

Upon the trachea, larynx, and root of the 
lungs, the respiratory murmur is heard per- 
fectly, but it has a particular character, which 
gives an idea of the air passing into a larger 
passage than that of the air cells. Neither 
do we distinguish the expanding of the pul- 
monary tissue, and the air seems to be attract- 
ed from the cylinder in inspiration and repell- 
ed in expiration. We may compare this 
mode of respiration, which we shall call 
tracheal, to the blast of a bellows * 

* Bronchial respiration (Bruit respiratoire bronchi- 
que) is the term by which M. Laennec designates the 
sound of the respiration as heard in the larynx, trachea, 
and larger bronchial trunks. — Vide Laennec, last edi- 
tion, p. 55 ; Forbes, p. 32. 

When the texture of the lungs becomes indurated 
from any cause, such as a pleuritic effusion or the 
changes occasioned by a severe peripneumony or hae- 
moptysis, the vesicular respiration having then disap- 
peared, or being much lessened, we can frequently 
perceive distinctly the bronchial respiration, not only 
in the large but even in the small ramifications of the 
bronchia. 

It is of great consequence to accustom ourselves to 
distinguish accurately the bronchial from the vesicu- 
lar or pulmonary respiration, not only on account of 
the great errors of diagonsis, which must result from 

**4 



30 OF AUSCULTATION IN 

2d. According to the frequency. The 
more frequent the respiratory murmur is, the 
noisier does it seem. A d&ep, slowly drawn 
inspiration, is sometimes scarcely heard : we 
*should therefore recommend that persons 
being examined should breathe somewhat 
quickly. 

3d. According to the age, sex, &c. In chil- 
dren, women, and men of a nervous constitu- 
tion, the respiration is sonorous and noisy ; the 
development of the cells is more easily ap- 
preciable, giving an idea of their bein^f a 
greater size or of dilating more. Tlw dif- 
ference of noise exists ehiefly in inspiration; 
it is less distinct in expiration ; the younger 
the child is, the more it is marked ; it con- 
tinues usually till puberty, or rather be- 
yond it. 

In adults the intensity of the noise varies 
much; there are some very healthy persons 

their being confounded, but because the former be- 
comes a pathognomic sign in several cases of impor- 
tance. In peripneumony it is one of the first indica- 
tions of hepatization, and commonly precedes the loss 
of the natural sound on percussion : it is likewise one 
of the earliest signs of an accumulation of tubercles in 
the upper lobes of the lungs. 



DISEASES OF THE CHEST. 31 

in whom it is scarcely heard unless they 
draw a full inspiration ; these ordinarily have 
their respiration frequent. In others it is 
strong enough without their being at all short- 
breathed. In fine, some persons preserve ar 
respiration similar to that of children, even to 
old age, and seem in the same degree more 
disposed to diseases of the respiratory organs. 

Art. II. — Natural Phenomena furnished 
by the Voice. 

The natural phenomena furnished by the 
voice, vary: 1st, According to the points ex- 
amined; 2d, According to the tone of the 
voice. When a healthy man speaks or sings, 
his voice resounds in the interior of the chest, 
and produces through the whole extent of 
this cavity, a sort of tremor, easily distinguish- 
ed on applying the hand. We shall not 
occupy ourselves with this tremor; it is a 
phenomenon of moderate importance, of 
which we rarely find occasion to take advan- 
tage. However, w 7 here a vast excavation 
exists, this tremor acquires such a force that 
it alone may make us suspect it. 

1st. According to the points. On applying 



32 OF AUSCULTATION IN 

the cylinder upon the thorax, a confused 
resonance of the voice is heard ; its intensity 
is not the same at all points. 

The parts where it is strongest, at the axilla, 
the back between the inner edge of the 
scapula and the vertebral column, the anterior 
superior part of the chest, towards the angle 
formed by the junction of the sternum and 
clavicle. 

At those spots the voice seems stronger 
and nearer to the observer than with the 
naked ear ; in other parts, more particularly 
below and behind, it seems w T eaker and more 
distant, and produces a confused sound, in 
which nothing articulate can be distinguish- 
ed. 

2d. According to the tone. In men who 
have a deep-toned voice, this resonance is 
stronger but flat, confused, and nearly equal 
at all points; it is clear and very distinct in 
persons whose voice has a sharp tone, in 
women and children. Finally, the agitated 
and trembling voice transmits the resonance 
very weakly, and in cases of aphonia is 
wholly absent. 



. . 



DISEASES OF THE CHEST. 33 

Art. III. — Natural Phenomena furnished by 
the Heart. 

These may be divided into four classes, 
and comprehend; 1st, The extent of the 
heart's pulsations; 2d, The shock which they 
communicate; 3d, The noise which accom- 
panies them; 4th, Their Rhythm. 

1st. Extent of the palpitation of the heart. 
In a healthy man of a moderate degree of 
plumpness, whose heart is of regular propor- 
tions, the beating of the heart can only be 
felt in the precordial region, that is to say, 
the space comprised between the fifth and 
seventh sternal ribs on the left side, and under 
the lower part of the sternum. The motions 
of the left cavities are felt in the first point, 
those of the right cavities in the second. 
When the sternum is short, the pulsations are 
still sensible in the epigastrium. 

In very fat persons, the pulsations of whose 
heart cannot be felt by the hand, the space in 
which they can be detected by the aid of the 
cylinder, is sometimes limited to a surface of 
about a square inch. Very thin persons, 
with narrow chests, offer the opposite dispo- 



34 OF AUSCULATION IN 

sition ; the pulsations of the heart have more 
extent, and may be felt in the third or even 
three-fourths of the inferior part of the ster- 
num, sometimes under the whole of this bone, 
in the left superior part of the chest as far as 
the clavicle, and even beneath the right cla- 
vicle. When the extent of the pulsation is 
limited to the points just mentioned, in per- 
sons such as we have pointed out, and they are 
less sensible under the clavicles than in the 
precordial region, the heart is still in good 
proportion. 

2d. The Shock. I understand by shock the 
sensation of impulse or percussion against 
the ear of the observer, arising from the 
pulsations of the heart. It is distinct with 
the cylinder when the hand applied upon the 
region of the heart can perceive nothing. 
This shock is very inconsiderable in a healthy 
man, particularly if tolerably plump. It 
is felt most in the precordial region and 
lower half of the sternum, and always with 
most force between the catilages of the fifth 
and sixth ribs, the part corresponding to the 
point of the heart. Its force varies greatly, 
according to the constitution of the individual ; 



DISEASES OF THE CHEST. 35 

it is therefore difficult to refer it to a uniform 
type. Practice teaches us to distinguish 
whether it be more or less intense than it 
ought to be; it should be rather less for the 
right ventricle than for the left. 

3d. The Noise. The alternate contrac- 
tions of the different parts of the heart return 
a sound insensible in the healthy state, but 
easily perceivable by the cylinder, however 
small may be the strength or volume of the 
organ. 

In the natural state this sound is double, 
and each pulsation of the heart corresponds 
to two successive sounds. 

One clear, abrupt, analogous to the sound 
of the clapper of the bellows, corresponds to 
the systole of the auricles; the other more 
flat and prolonged, coincides with arterial 
pulsation, as well as with the sensation of 
the shock mentioned in the preceding arti- 
cle ; it is produced by the contraction of the 
ventricles. 

The noise of the right cavities is heard at 
the lower part of the sternum ; that of the 
left cavities between the cartilages of the 
ribs. It is always stronger in the precordial 



36 OF AUSCULTATION IN 

region than in the other points of the chest, 
where it may become developed in persons, 
who, [though otherwise healthy, have a heart 
with very thin walls. We observe also in them, 
that the sound of the auricles is more sonorous 
under the clavicles than that of the ventricles, 
which does not exist in the precordial region. 
In persons in whom the pleura and anterior 
border of the lungs is prolonged before the 
pericardium, the noise of the auricle is duller 
and more obtuse than that of the ventricles, 
without ceasing to be distinct. That de- 
pends without doubt on its being masked by 
the murmur of respiration, or by that pro- 
duced by the air pressed out from this por- 
tion of the lung, by the heart's pulsation. 
4th. Rhythm. We understand by the term 
Rhythm, the order of the contractions of 
the different parts of the heart, as they are 
heard by the cylinder, their respective dura- 
tion, their succession, and general relation to 
each other. In a healthy man, whose heart 
is in a state favorable to the performance of 
all its functions, at the moment in which the 
artery strikes the finger, the ear applied upon 
the cylinder is gently raised by a movement 



DISEASES OF THE CHEST. 37 

of the heart, isochronous to that of the artery, 
and accompanied with rather a dull sound ; 
it is the contraction of the ventricle. Im- 
mediately after, and without any interval, a 
shorter, louder sound announces the contrac- 
tion of the auricle ; no movement sensible to 
the ear accompanies this sound. An inter- 
val of repose succeeds to it. This interval, 
although short, is well marked. After it a 
new complete contraction of the heart is per- 
ceived. 

The respective duration of the contraction 
of the auricles and ventricles appears deter- 
mined with sufficient precision as follows. 
Of the total period taken up by a complete 
contraction and repose of the heart, a third to 
a fourth is occupied by the systole of the au- 
ricles; rather less than a fourth by the 
absolute repose; the rest by the contraction 
of the ventricles. These relations exist, 
whatever be the swiftness or slowness, the 
frequency or rarity of the movements, when 
the organ is healthy and well proportioned. 



38 PATHOLOGIC PHENOMENA IN 



SECTION II. 

Pathologic Phenomena. 

By pathologic phenomena, we mean the 
modifications of the natural phenomena pro- 
duced by some lesion of the organ in which 
they are observed. We shall refer them to 
four principal divisions. Phenomena furnish- 
ed, 1st, By the respiration; 2d, By the 
voice; 3d, By the respiration and the voice; 
and, 4th, By the heart. 

Art. I. — Phenomena furnished by the res- 
piration. 

The respiration may be stronger than in 
the natural state; it may be more feeble, 
wholly absent, or it may be analogous to that 
variety we have called tracheal. It may be 
pure, or combined with different kinds of 
rattle. 

When the respiration becomes stronger 
than in the natural state, it assumes the 
character of that observed in infants, and 
has, for that reason, been named by M. Laen- 



DISEASES OF THE CHEST. 39 

nee, puerile respiration. This increased in- 
tensity of the respiratory murmur is never 
observed in cases of lesion of the lung, or of 
a part of the lung. It is met only in the 
healthy parts of the lung, the action of which 
is temporarily increased to supply the loss of 
the part diseased. Thus in pneumonia, it is 
not uncommon to find the respiration puerile 
in the parts not affected by the disease. 
However, we see this exaggeration of respira- 
tion coincide with a great dyspnoea, in some 
cases of asthma and of hysteric suffocation : it 
is difficult to account for this anomaly. We 
have thrice observed the respiration stronger 
than in the healthy state, in parts which have 
been attacked with pneumonia on the follow- 
ing day. This respiration was not truly 
puerile ; it seemed to occur in a vast cavity im- 
mediately below the cylinder nearer to the sur- 
face of the body than it does in the thinnest 
persons. 

In those three cases the peripneumony per- 
haps already occupied the centre of the organ, 
and the air vessels nearest to the surface 
alone were fit for carrying on respiration. 

The respiratoray murmur offering numer- 
ous varieties in the healthy state, it is only by 



40 



PATHOLOGIC PHENOMENA IN 



examining different parts of the pulmonary 
organs *that we can judge of its diminution. 
This comparison is always easy, for it is rare 
to find the respiration weakened in a whole 
lung, or in both together. The intensity of 
the noise offers many degrees, from a slight 
diminution to the most complete absence. 
The small extent of the movements of the 
thorax seems most commonly to be the cause 
of this diminution : it often depends also on 
the incomplete obstruction of the bronchial 
tubes of the middle size, owing to swelling of 
their lining membrane, or to the presence of 
accumulated sputa. We find it also in cases 
of membranes continuing soft, and only 
beginning to be organized. * 

The absence of the respiratory murmur 
may proceed from many causes. It o£^urs 
when the lung is become impermeable to 
the air, or when a liquid is interposed be- 
tween it and the thoracic walls, or any other 
body accidentally developed, which prevents 
the transmission of the sound. It is rarely 
observed in the whole extent of one side of 
the thorax. The clavicles and the root of 
the lungs are the points where it occurs most 



DISEASES OF THE CHEST. 41 

rarely ; perhaps never in the latter of these 
parts. 

The tracheal respiration, of which we have 
spoken in treating of the natural phenomena, 
is sometimes observed in other points than 
those in which it is perceived in the healthy 
state. It cannot take place unless there be 
formed in the lung an excavation of con- 
siderble size, communicating freely with the 
bronchia, or being continuous with them. It 
has seemed to me also to arise from a harden- 
ing of the hepatized pulmonary tissue, which 
transmits to the ear the motion of the air in 
the great bronchial pipes, more noisy from 
the impossibility which the induration offers 
to the penetration of the air into the bronchial 
vesicles. Whatever be the intensity of the 
respiratory murmur, it may be either pure, 
which indicates that the bronchia are per- 
fectly free, or it may be attended with rat- 
tles. 

We understand by the term rattle * every 

* The term rale, which is here translated rattle, was 

adopted by Laennec to express the rattling, or wheezing 

noise described above. The Latin word Bhoricus, 

(gr. w) was afterwards substituted by Laennec 

*5 



* • 



42 PATHOLOGIC PHENOMENA IN 

kind of noise attending the circulation of air 
in the bronchia and vesicles, different from 
the murmur produced by it in the healthy 
state. 

The rattles rarely occupy all the extent of 
the organ ; most commonly they are per- 
ceptible only in an inconsiderable extent, 
and the respiration remains natural, or even 
becomes puerile in the rest. They announce 
either the contraction of some part of the 
bronchial tubes, or their being gorged by 
some fluid, or finally, a similar state of the air 
vesicles. 

Their difference, their remoteness or close- 
ness, and the extent that they occupy, will 
point out tolerably well the place where these 
liquids exist, and most of their physical pro- 
perties. At a small distance from the spot oc- 
cupied by any lesion of the lungs, the rattle 
characterizing it ceases to be heard, and the 
respiration may be natural, although in the 
vicinity of a part very deeply affected. We 
shall distinguish four principal kinds of rattle :— 

himself, and being taken from a language not in 
common use, will better retain its precise and techni- 
cal meaning. — Ed. 



DISEASES OF THE CHEST. 43 

1st, The dry sonorous rattle: 2d, The his- 
sing; 3d, The mucous; 4th, The crepitating. 
Among these the greatest number are best 
heard during the act of respiration, others 
during the act of coughing. Each kind may 
exist alone, or combined with two or three 
others, either in the same point, or at different 
points. Some are permanent during the whole 
duration of the disease, which they serve 
to characterize; others are as it were in- 
termittent, appearing and disappearing by 
turns, occupying at one moment one spot, 
soon after another ; so that they may be 
absent at one moment in a part where they 
had been heard the instant before. 

The sonorous rattle. — This consists in a 
sound more or less grave, and often extremely 
noisy, resembling at one time the snoring 
of a sleeping man, at another the sound pro- 
duced by rubbing the string of a bass viol 
with the finger, and frequently the cooing of 
a dove. It appears to be owing to the con- 
traction of the bronchial tubes by the swelling 
of their lining membrane, or to some change 
in the form of these canals, perhaps to the 
thickening of the spurseperons at the point of 



44 PATHOLOGIC PHENOMENA IN 

division of the bronchia, a thickening we al- 
most constantly observe in subjects who have 
fallen during the continuance of a catarrh, 
either acute or chronic 

The sibilant or hissing rattle. — It resem- 
bles a prolonged hiss, and accompanies either 
the end or commencement of inspiration, or 
of expiration. It is grave or acute, dull or 
sonorous. These two varieties are some- 
times met together in different parts of the 
lung, or succeed each other in the same point, 
at closer or more distant intervals. It de- 
pends on the presence of mucosity, not very 
abundant, but thin, viscous, obstructing more 
or less completely the small bronchial rami- 
fications which the air must traverse to reach 
the air vesicles. It seems to me to indicate 
an alteration of the lung, deeper than the pre- 
ceding, that is to say, occupying finer rami- 
fications; and when it is heard in a great 
part of the organ it is attended with more con- 
straint of respiration. It is during the ex- 
istence of the sibilant rattle that we observe 
those mucous sputa of an arborescent appear- 
ance, presenting to the eye the form, calibre, 
and ramifications of the small tubes from 




DISEASES OF THE CHEST. 45 

which they have been propelled by the effort 
of coughing. 

The mucous rattle. — This rattle, produced 
by the passage of the air through sputa accu- 
mulated in the bronchia or trachea, or through 
softer tuberculous matter, denotes by its nature 
the unctuous untenacious state of the liquid 
which fills the air tubes. At one time it is 
weak, and produced at remote intervals ; at 
another it is strong and persistent. In the 
first case it may be judged that the column 
of air meets only at intervals the mucosity 
which produces it; in the second, that the 
bronchia are almost entirely filled with it. 
Carried to the highest degree it constitutes 
gurgling, the name by which we characterize 
the noisy murmur caused by the agitation of 
tuberculous matter, or purulent sputa, with 
the air traversing them. 

Crepitating rattle.— This consists in a 
noise which may be justly compared to that 
of butter boiling, or of salt crackling on a hot 
bassine plate, or to that produced by squeez- 
ing a bit of dried healthy lung between the 
fingers. It seems to be owing to the exha- 
lation of blood into the air cells, observed in a 




46 PATHOLOGIC PHENOMENA IN 

lung affected with the first degree of pneu- 
monia, of which the crepitating rattle is the 
pathognomonic sign. A new proof of the 
reality of this cause may be drawn from an 
analogous kind of injury in oedema of the 
lung, characterized by a variety of this rattle 
of which I am about to make mention. This 
variety has very striking characters ; and if 
w T e have not made a particular species of it, it 
is because it is difficult to describe its differ- 
ences exactly, though they are very sensible 
to the ear; and it is enough to have heard 
the two kinds once, not to confound them 
afterwards. The name of subcrepitating, 
given to it by M. Laennec, indicates its char- 
acter well. In reality, this rattle is analogous 
enough to the first, but it gives a sensation 
to the ear that the liquid which produces it 
has more tenuity and less plasticity than the 
crepitating rattle. On opening the dead 
bodies of subjects affected with oedema 
of the lungs, we find this viscus filled with a 
a limpid serous fluid without viscosity which 
fills up the bronchia and vesicles, and is 
filtrated into the interlobular cellular tissue, 
rendering the lung flaccid and inelastic. 



DISEASES OF THE CHEST. 47 

Such arc the different rattles audible with 
the cylinder. We see by their description 
that they cannot be mistaken, and each offers 
very striking characters ; but their differences 
are often less sensible, and shades, which 
practice teaches us to seize, and which words 
cannot express, establish a sort of transition 
between each of them, and indicate a mixed 
lesion, more or less like that indicated by 
each individually. 

Art. II. — Phenomena furnished by the Voice. 

The phenomena presented by the voice are 
of three sorts; Resonance, Pectoriloquy, and 
Hsegophony. 

Resonance*. I understand by resonance, a 
more than naturally sonorous resounding of 
of the voice, existing in a part in which it 
cannot be perceived in the healthy state. 

Resonance offers no articulated sound; it 
seems but a confused noise, scarcely approach- 

* Resonance is often mistaken by beginners for 
pectoriloquy, though the directions given in the text 
ought to prevent the mistake. It often exists for a 
long time below the clavicle, before the formation of 
a cavity gives rise to pectoriloquy. 



48 PATHOLOGIC PHENOMENA IN 

ing the extremity of the tube of the cylinder 
below which it takes place, and never ap- 
pearing to enter the canal so as to reach the 
ear of the observer. 

The hardness of the pulmonary tissue, its 
compactness, produced either by a mass of 
unripe tubercles, or by inflammatory action, 
seems to me to be the cause of this want of 
articulation, by rendering the lung more fitted 
to transmit the murmur of the voice from the 
bronchia. This symptom, usually of little 
importance, sometimes acquires considerable 
value, by comparing the two sides of the chest, 
and from its coexistence with other modes of 
research*. 

* Bronchophony. ( Bronchophonie. Laennec, vol. i. 
p. 64. Bronchophonism, Forbes, p. 36.) 

In persons of a delicate frame, particularly in lean 
children, there frequently exists in the situation of the 
bronchia, a bronchophony very similar to laryngo- 
phony. 

The sound of the voice is scarcely at all perceptible 
in the bronchia distributed through the lungs, when 
these organs are healthy ; but in disease of the voice 
may become perceptible in the smaller bronchial 
tubes. Thus it is found that an attack of peripneumony, 
an extensive haemoptysical induration, or the accumula- 
tion of a great number of tubercles in the same point, 



DISEASES OF THE CHEST. 49 

Pectoriloquy*. This is said to be present 
when the patient's voice, distinctly articu- 
lated, seems to proceed from the point of the 
chest on which the instrument is placed, and 
to pass through the tube of the instrument to 
the observer's ear. 

It is perfect, imperfect, or doubtful. Perfect 
pectoriloquy is that which presents all the 
characters we have just mentioned, that is, 
in which the voice, clear and well articulated, 
traverses the cylinder and arrives at the ear 
of the observer either with its natural tone, 
or with a stronger one. It is imperfect, when 

by condensing the texture of the lungs, gives rise to a 
sound analogous to pectoriloquy. This accidental bron- 
chophony is most marked when the pulmonary indura- 
tion takes place near the root of the lungs. This sign 
is one of the best to measure the progress of a recent 
peripneumony. 

The dilatation of the bronchia, or the accumulation of 
tubercles, separately or combined, may give rise to the 
same phenomenon. Bronchophony is rarely so like 
pectoriloquy as to deceive a person even of moderate 
experience. 

* Whenever we are doubtful of pectoriloquy, it is a 
good plan to compare it with the sound produced by 
applying the cylinder upon the trachea while the pa-, 
tient is speaking. 

6 



n 



50 PATHOLOGIC PHENOMENA IN 

the articulated voice resounds with force 
under the cylinder, and appears closer to the 
ear without entering the tube completely. 
Finally, it is doubtful, when, as with ventrilo- 
quists, the voice seems sharp and unnatural, 
and does not traverse the tube ; it is little 
more than resonance. Imperfect and doubt- 
ful pectoriloquy only deserve attention when 
they exist but at one side, or are joined to 
other signs drawn from examination of the 
respiration. 

The most perfect pectoriloquy may some- 
times assume the characters of the imperfect 
or doubtful kind ; it may also disappear from 
time to time, or become as it were intermit- 
tent : we will state in what circumstances, 
after having explained the causes of pectori- 
loquy. 

This phenomenon is always owing to the 
presence of excavations in the lung, commu- 
nicating freely with the bronchia, and wholly 
or partly empty. It may be met with in all 
points of the chest ; but the parts in which it 
is observed the most frequently, are, below 
the clavicles, in the hollow of the axilla, the 
space between the clavicle and the trapezius 



DISEASES OF THE CHEST. 51 

muscle, the supra and infra spinal fossa. 
These parts all correspond to the summit of 
the organ, and it is in that part in reality, that 
excavations, produced by the softening of tu- 
bercles, are most frequently detected. 

Pectoriloquy offers some variety, arising 
from difference in the tone of the voice, the 
size of the cavity, its form, the firmness or 
softness of its walls, their adhesion or want 
of adhesion to the costal pleura, or to the 
difficulty with which the air penetrates them. 

1. The more acute the voice is, the more 
evident is the pectoriloquy ; it is almost al- 
ways imperfect and sometimes doubtful in 
persons of a deep-toned voice. Aphonia does 
not make it disappear completely ; and it 
often happens in these cases, that we can 
distinguish what the patient says, better with 
the cylinder applied to the point of the chest 
where the cavity exists, than with the naked 
ear at the same distance. 

2. Perfect pectoriloquy requires the cavity 
to be of moderate extent. In very large cavi- 
ties it changes to a stronger, deeper sound, 
analogous to that of the voice transmitted to 
some distance through a scroll or trumpet 



52 PATHOLOGIC PHENOMENA IN 

made of paper. In very small caverns it is 
often doubtful, particularly when the excava- 
tion is central, and surrounded with parts of 
the lung still permeable to the air. 

3. The winding disposition of the cavities, 
or the direct communication of a number of 
excavations with one another, give something 
of a confused or stifled sound to the pecto- 
riloquy ; the voice seems badly articulated. 

4. The firmer and thinner the walls, the 
more perfect the pectoriloquy. When cica- 
trization has produced a membrane of a fibro- 
cartilaginous nature over the whole surface 
of one of the cavities, pectoriloquy acquires 
a metallic tone, sometimes so noisy as to 
injure the clearness of the perception of the 
sounds. 

5. An excavation placed near the surface of 
the lung, the thin wall of which does not 
adhere to the costal pleura and sinks in expi- 
ration, does not yield pectoriloquy ; we then 
recognize its existence by other characters. 
On the other hand, a superficial excavation 
with thin adherent walls, gives a striking 
pectoriloquy with a force which fatigues the 
ear* 



DISEASES OF THE CHEST. 53 

6. The less fluid there is in the excava- 
tion, the more evident is the pectoriloquy, 
because the communication with the bronchia 
is then usually large, and permits a free ac- 
cess to the air. However, this communica- 
tion may be destroyed more or less completely, 
and for a longer or shorter time, by the stag- 
nation of the sputa in the bronchial tubes ; it 
is this which sometimes renders pectoriloquy 
doubtful, and gives it that intermittent char- 
acter not rarely observed. There are days 
in which we can hardly find one case of it in 
a ward in which the day before we observed 
a great many : we perceive then that in most 
cases the expectoration has been but small, 
or wholly deficient- 

Pectoriloquy is produced by the voice re- 
sounding in those excavations. However, I 
am about to state facts which prove, that, 
although pectoriloquy is the pathognomonic 
sign of the existence of an accidental cavity of 
the lung, it may be produced without that 
alteration existing, in circumstances proper 
for increasing the natural resonance of the 
voice in the bronchia, or at least that a phe- 



*6 



54 PATHOLOGIC PHENOMENA IN 

nomenon then manifests itself, almost per- 
fectly resembling pectoriloquy. 

Six patients were brought into the hospital 
" Neckar" at not very distant periods ; they 
were affected with pneumonia occupying the 
upper lobe of one of the lungs. All pre- 
sented evident pectoriloquy at the upper part 
of the chest, from the change of the first to 
the second stage, and during the whole dura- 
tion of the latter. Two died ; the first dur- 
ing the acute stage of the disease. On in- 
spection we found a single very small abscess, 
situated in the centre of the summit of the 
organ, and which seemed to me entirely filled 
with pus, and consequently without commu- 
nication with the bronchia ; the rest of the 
lobe was hepatized and very dense. The 
second succumbed after some months of dis- 
ease, in which he presented most of the 
symptoms of the third degree of pulmonary 
phthisis. He had been pectoriloquous in a 
high degree, and expectorated a large quan- 
tity of suspicious looking sputa. In him 
the summit of the lung was found hollowed 
out with a number of vast cavities, commu- 
nicating freely with each other, and covered 



DISEASES OF THE CHEST. 55 

over by a thin pseudo membrane firm enough 
to be divided into layers. (The disease had 
lasted three months.) The rest of the lobe 
was in a state of grey hepatization, and had 
acquired a remarkable density. No tubercles 
were found in any viscera, nor in the hard- 
ened portion. The other four patients, who 
were cured in a tolerably short period, ceased 
to be pectoriloquous before leaving the hospi- 
tal, and,in proportion as the respiration return- 
ed, the lung recovering its permeability, the 
phenomena diminished in them. During the 
whole continuance of the disease, their sputa 
was simply mucous, or viscous and tena- 
ceous, or pituitous, but never purulent or 
puriform. 

From these observations does it not seem 
demonstrated, that in cases of hepatization, 
or condensation of the pulmonary tissue, 
pectoriloquy may exist in a more or less per- 
fect degree, if the part thus hardened be 
close to the trachea or in contact with it, or 
traversed by large bronchial tubes ? 

The pulmonary tissue, from its acquired 
density, is become more fitted for receiving 



56 PATHOLOGIC PHENOMENA IN 

and transmitting the vibrations of neighbor- 
ed o 

ing bodies and of those it surrounds. 

M. Cruveilhier also made this observation, 
and has explained it publicly in his lecture on 
pneumonia, at the Faculty of Medicine of 
Paris, on the occasion of the " Concours" 
for the situation of aggrege. 

Egophony (or haegophony*) is a strong 
resonance of the voice, more sharp, more 
acute, than that of the patient ; in some de- 
gree argentine, jerking, and tremulous, like 
that of a kid.f This phenomenon may be 
produced in the whole extent of the chest, 
on one side only, or on both sides at once ; 
but it is rarely that it is not confined to a 
tolerably circumscribed space, of which the 
vertebral column, the inner border of the 
scapula, its inferior angle, and its outer edge, 
form the limits. 

When it exists on both sides together, it 
is difficult to decide whether it be a conse- 
quence of disease : in some subjects the 

* JEgopJionism, Forbes. 

f It often closely resembles the voice of Punchi- 
nello, and considering the part it is heard in, can 
hardly be mistaken for any of the other phenomena. 



DISEASES OF THE CHEST. 57 

natural resonance of the voice at the root of 
the lung has this sharp bleating character. 

Haegophony varies much hi force and ex- 
tent ; but however weak it may be, it seems 
to me always to indicate with certainty the 
existence of a moderate quantity of liquid 
in the cavity of the pleura, or of pseudo 
membranes tolerably thick, and still soft. 

When the effusion becomes too abundant 
or too small in quantity, hsegophony ceases 
to exist. I have never found it when the 
effusion of the liquid took place very rapidly, 
and the affected side was filled almost sud- 
denly. 

Can this phenomenon be explained by 
the quivering of the voice on the surface of 
the liquid, as M. Laennec formerly thought ? 
Or is it owing to the flattening of the bron- 
chial tubes, as he teaches at present ? 

A woman presented haegophony towards 
the root of each lung in turn : she died. No 
liquid was found extravasated ; the flatten- 
ing of the bronchia was not very evident. 

Another died after long suffering. For 
three years she had been pectoriloquous in the 
summit of the lung, and haegophonous at the 



58 PATHOLOGIC PHENOMENA IN 

root of that organ in a very circumscribed 
space. There was no extravasation, and 
although surrounded by a very dense pulmo- 
nary tissue, the bronchia did not appear to 
me altered in their form. 

A man was carried off by pneumonia ; the 
dulness of percussion, the presence of hsego- 
phony, and the absence of all respiratory 
murmur, had made the existence of effusion 
be suspected : four hours before death the 
patient was still hgegophonous. There was 
no liquid extravasated however ; but there 
was a tolerably thick and slightly consistent 
layer of false membrane upon the root of the 
lung;. The bronchial tubes offered nothing; 
particular. I will confess that it is very dif- 
ficult to discern whether there is flattening 
of these tubes or not ; they are not natural- 
ly cylindrical, and perhaps a very slight de- 
gree of closing may cause hsegophony. 

These three facts, unique as far as I know, 
do not hinder me from believing that this 
phenomenon indicates with certainty a mod- 
erate extravasation of fluid into the cavity of 
the thorax ; but they seem to me sufficient 
to make us reject the first explanation of 



DISEASES OF THE CHEST. 5$ 

haegophony, and insufficient to prove the 
second.* 

* The student will do well to consult the last edition 
of Laennec, and the able translation of that work by 
Dr. Forbes ; the former, vol. i. p. 69 ; the latter, p. 39. 
The following are extracts : 

"iEgophony may be readily confounded by the inex- 
perienced with pectoriloquy ; and still more so with 
bronchophony. Laennec himself was long guilty of 
this mistake. The distinction is easy when the respec- 
tive characters of each are strongly marked ;. but there 
occur cases in which this is hardly practicable." 

" Laennec observes, ' In comparing the results of 
my early and more recent experience respecting 
aegophonism, it seems to me certain that it exists only in 
cases of pleurisy, either acute or chronic, attended by 
a moderate effusion in the pleura, or in hydrothorax or 
other liquid extravasation in the same cavity.' 

" All the cases in which I have observed aegophon- 
ism, since I have been able to discriminate it from 
pectoriloquism and bronchophonism, have at the same 
time afforded other undoubted signs of effusion into 
the chest. In the examples of pleurisy which I have 
been able to attend to from their commencement to 
their close, I have found it as early as the first hours 
of the attack ; but it has never been observed strongly 
marked until the second, third or fourth day, and 
hardly ever until after the sound of respiration has 
become almost or altogether inperceptible in the 
affected side, and until this has yielded the dull sound 



60 PATHOLOGIC PHENOMENA IN 

Art. III. — Phenomena furnished by the Res- 
piration and Voice. 

Metallic respiration, resonance, and tink- 
ling. These three phenomena are very re- 
markable. Let us first explain the lesions 

cm percussion. I have observed aegophonism in every 
case of pleurisy which has come under my care during 
the last five years, except in a very few slight acute cases, 
where the effusion (as proved by the auscultation of 
the respiration, and by percussion) was inconsiderable, 
and in those which did not come under my notice 
until far advanced, and when they were in progress 
towards recovery. I have discovered this sign where 
there did not exist more than three or four ounces of 
fluid in the chest. ^Egophonism decreases and gradual- 
ly disappears as the effusion is absorbed. In very acute 
cases, it exists frequently two or three days only, and 
then totally disappears. In the chronic state of the 
disease, with moderate effusion, I have found it some- 
times continue for several months with variations of 
intensity proportioned to the varying quantity of the 
effused fluid. When this is very great, particularly 
when it is sufficient to cause dilatation of the chest, 
segophonism ceases entirely. * * * * 

^Egophonism,is not, like pectoriloquism, confined to 
one point, but extends over a certain continuous por- 
tion of the chest. * * * 



DISEASES OF THE CHEST. 61 

which they indicate, that we may render 
their explanation more easy to comprehend. 

These morbid states are a fistulous com- 
munication between the cavity of the pleura 

"I consider segophonism to be owing to the natural 
resonance of the voice in the bronchial tubes, rendered 
more distinct by the compression of the pulmonary 
texture, and by its transmission through the medium 
of a thin and mobile layer of fluid. This opinion is 
supported by many facts and reasons. The points 
where it is constantly found, correspond with the up- 
per border of the fluid, and where it is of the least 
thickness." 

"From the preceding observations I think we are 
entitled to conclude, that segophonism is a favorable 
sign in pleurisy, as it seems uniformly to indicate a 
moderate degree of effusion. Its continuance for 
some time is a favorable omen, as showing that the 
effusion does not increase ; if it continues as long as 
the fever, or longer, we may be assured that the disease 
will not become chronic, as this never happens except 
when the effusion is extremely abundant. I have 
frequently drawn this prognostic, and have never been 
deceived in it. 

" When I published the first edition of this work, I 
was not quite sure that segophonism might not exist 
in simple peripneumony ; farther experience, however, 
has completely convinced me that this cannot be the 
case. 

7 



62 PATHOLOGIC PHENOMENA IN 

and the bronchia, and the accumulation of a 
certain quantity of air in the sac formed by 
that membrane ; an effusion both liquid and 
gaseous, with or without communication ; 
finally, a very large excavation, with thin and 
compact adherent walls. Metallic respira- 
tion, and metallic resonance, will exist in the 
first case ; metallic tinkling will be joined to 
them in the third, or will be found alone if 
there be no bronchial fistula. 

If we make a patient in whom this com- 
munication exists, breathe strongly, the air 
in penetrating the pleural cavity, produces a 
murmur similar to that caused by blowing 
into a rather narrow-mouthed metal vessel. 
If we make him speak, his voice bounds 
under the cylinder, and resounds as if he 
spoke in a cistern. This is the more strik- 
ing, as the phenomenon is sometimes evident 

"The following positions seem proved: 1. That 
gegophonism exists in simple pleurisy, and in no 
case with more decided characters ; 2. That broncho- 
phonism exists frequently in peripneumony, and with 
features sufficiently well marked to distinguish it from 
segophonism ; 3. That both these co-exist in certain 
cases of pleuro-peripneumony." — Ed. 



DISEASES OF THE CHEST. 63 

only at the end of the sentence, and seems 
to be an echo. 

Finally, if an effusion both gaseous and 
liquid exist, and we make the patient rise, to 
examine him, it sometimes happens that we 
hear a sound of short duration, similar to that 
of a drop of water falling into a decanter 
three fourths empty. It seems as if a drop 
remained sticking to the upper part of the 
cavity, and falling into the lower part, then 
occupied by the effused fluid, produced this 
noise by its fall into the mass of liquid. 

These phenomena never fail to become 
evident, from time to time, at least during 
the continuance of the symptoms they denote. 
It is scarcely necessary to say that we often 
examine the patient several times before an 
opportunity occurs of hearing them. The 
obstruction of the fistula or bronchia commu- 
nicating with it makes them disappear. A 
certain proportion between the liquid and 
gaseous effusion is necessary for their pro- 
duction in a very distinct degree. 

Agitation of the air, its passage through a 
narrow opening, and the resounding of the 
voice in a large cavity with firm walls, half 



64 PATHOLOGIC PHENOMENA IN 

solid and capable of vibrating with force, 
easily account for the metallic respiration 
and resonance. The explanation of the 
tinkling which I have given, seems probable 
enough.* 

Art. IV. — Phenomena presented by the 
Heart. 

These pathologic phenomena, like the na- 
tural ones, are referable ; 1st, To the extent 
in which we hear the pulsations of the heart, 
by the aid of the cylinder ; 2d, To the shock 
or impulse of the organ ; 3d, To the nature 
or intensity of the noise caused by its con- 
tractions ; 4th, To the rhythm, according to 
which its different parts contract. 

1st, Extent. The extent of its pulsations 
may exceed their natural limits, or be con- 

* In the last edition of Laennec, the author states, 
that the metalic tinkling always originates in a morbid 
excavation within the chest, containing partly air, and 
partly liquid. It exists only therefore in two cases ; 
viz. where a serous or purulent effusion coexists with 
pneumo-thorax ; or when a very large tuberculous ex- 
cavation of the lung is only partly filled with very 
liquid pus. — Ed. 



DISEASES OF THE HEART. 65 

fined to a very small surface. But before 
entering into any details on this subject, it is 
necessary to establish a distinction between 
the extent in which we hear the pulsations, 
and that in which they may be felt. 

The increase of extent in which the pul- 
sations become evident, is usually in the fol- 
lowing order: 1st, The left side of the chest, 
from the axilla to the region corresponding 
to the stomach ; 2d, The right side in the 
same extent ; 3d, The left posterior part of 
the chest ; 4th, Lastly, but rarely, the poste- 
rior part of the right side. The intensity of 
the sound is progressively less in the succes- 
sion indicated. 

The possibility of hearing the heart in 
these different regions always indicates a 
state of weakness of the organ, a small de- 
gree of thickness of its walls, particularly of 
the ventricles ; the passive dilatation of some 
of its parts. 

It may also depend on causes not con- 
nected with the heart, the action of which 
may be either permanent or temporary ; such 
are the thinness or narrowness of the chest, 
hepatization of the lung, its compression by 
*7 



66 PATHOLOGIC PHENOMENA IN 

effused fluid, the existence of excavations 
with firm walls, pneumo-thorax, nervous 
agitation, an intense fever, palpitation, he- 
moptysis, and in general all the causes which 
increase the frequency of the pulse. 

The diminution of the extent in which 
the heart's pulsations can be heard, usually 
announces a more or less marked thicken- 
ing of its walls ; it is not very often ob- 
served. 

It is less rare to observe, that in the same 
circumstances, the pulsations of the heart 
seem to confine themselves so as to be felt 
in a smaller extent than in the sound state ; 
on the contrary, when the heart is dilated, it 
strikes the sternum by a large surface. The 
two last observations are not always correct: 
I have met with numerous exceptions. 

2d, Impulse. We have said, how many 
varieties the intensity of the shock of the 
heart in the healthy state offered to the ear, 
so it is very difficult to pronounce decidedly 
upon its increase or diminution, unless they 
are strongly marked, or do not exist at both 
sides at once, which is generally the case. 



DISEASES OF THE HEART. 67 

The increase of impulse offers numerous 
degrees, from a slight excess of force, to that 
violent shock which communicates a disa- 
greeable stroke to the head of the observer, 
and raises the walls of the- thorax strongly 
enough to be visible at a certain distance. It 
is almost always in direct proportions to the 
thickness of the ventricular walls, and in in- 
verse proportion to the extent of the pulsa- 
tions : it is then the pathognomic sign of 
hypertrophy of this organ. 

Quick walking, running, ascending, nervous 
agitation, palpitation, fever, may produce it 
temporarily without any alteration of the 
heart ; so we should not proceed to an exami- 
nation till after a considerable repose of body 
and mind. Venesection lessens this impulse ; 
we should judge badly of its degree after this 
operation. 

The diminution of the impulse, though 
rarely, is sometimes as exaggerated as its in- 
crease ; it depends at one time on the weak- 
ness of the organ, the small degree of thick- 
ness of its walls, and coincides with extended 
pulsations ; at another, on extreme obstruc- 
tion of respiration, on the difficulty of pul- 



68 PATHOLOGIC PHENOMENA IN 

monary circulation, and may then coexist 
with a well characterized hypertrophy. This 
diminution is often observed in the latter 
stages of the complaint ; certain affections 
of the mind, fear, depressing passions, may 
also produce it. 

3d, Sound. The sound of the contractions 
of the heart may become dull or more clear, 
more sonorous than in the natural state. It 
may give rise to sounds wholly new, of which 
not even the rudiments can be perceived in 
the healthy state of the organ. 

The diminished intensity of the sound 
seems to depend on the softening of the tissue 
of the organ, or on an increase of the thick- 
ness of its walls ; it is, with feebleness of 
impulse, the only sign furnished by the cylin- 
der of the first of these affections, a disease 
rare and most usually mistaken. 

The clearness, the sonorousness of the 
contractions is much more frequently observ- 
ed ; it is always met with in a heart having 
thin walls, and indicates this natural or pa- 
thological condition. This clear noise may 
proceed from the auricles or the ventricles. 
The time and place at which it is heard, in- 



DISEASES OF THE HEART. 69 

dicate the part which gives rise to it ; it al- 
ways announces a thinness of the portion of 
the heart of which the contraction takes 
place. 

As to the sounds which present them- 
selves, not having any rudiment in the heal- 
thy state, we shall refer them to three heads. 
1st, The bellows blast; 2d, The rasping 
noise ; 3d, That which has some resemblance 
to the creaking of new leather. 

1 st, The belloios blast , tolerably well char- 
acterized by its name, may accompany the 
contraction of the different parts of the heart, 
or that of the arteries, either all at once or 
partially. It may be constant, or only return v 
from time to time without any appreciable 
cause, on the slightest movement, or from the 
slightest emotion. The nervous, the hysteri- 
cal, and hypochondriacal, those subject to 
any hemorrhage, present this phenomenon 
most frequently, without any alteration of 
the heart's structure, or any disturbance of its 
functions. It may also exist during disease 
of this organ in persons of none of the above 
dispositions. 



70 PATHOLOGIC PHENOMENA IN 

At the opening of the dead bodies of those 
who have presented it in the highest degree, 
and in the most constant manner, in the heart 
and arteries, we do not meet any constant 
lesion to which it may he reasonably attri- 
buted. 

M. Laennec regards it as indicative of a 
simply spasmodic state of the circulating 
vessels, or of some part only of the sangui- 
neous system. Many observations seem to 
prove this opinion : — 1st, Its analogy to the 
noise produced by a forced muscular contrac- 
tion, of which it is easy to assure ourselves. 
In fact, if we support the elbow upon a table, 
rest the ear forcibly upon the hand, and con- 
tract and relax the lower jaw alternately with 
energy, we hear a sound quite similar. 2d, 
The facility with which we cause it in some 
persons in a great number of arteries alter- 
nately, by resting lightly upon a point of the 
vessel, contracting its calibre, and thus offer- 
ing to the course of the blood an obstacle 
which does not completely retard its progress. 
3d, Its appearance before active hemorrhages 
in the vessels which carry the blood to the 
part through which the hemorrhage is about 



DISEASES OF THE HEART. 71 

to take place. 4th, Its constant existence in 
cases of palpitation produced by anemia. 

I know that these ideas upon the bellows 
blast naturally lead to the admission of the 
power of contraction in arteries, and repre- 
sent them as in a part independent of the 
heart. But do not other facts render this 
almost evident ? Thus the very common 
want of proportion between the force of the 
heart's pulsations and of those of the arteries ; 
the development of the circulating pheno- 
mena in a part of small extent, the rest of the 
system remaining in the most perfect calm ; 
that unusual sensation of pulsation which at- 
tends some inflammations, whitlow, for exam- 
ple, a sensation which is not illusive, since 
the finger applied upon the diseased part 
feels the same sensation ; the pulsations felt 
within the cranium of persons suffering from 
hemicrania ; the non-transmission of all the 
pulsations of the heart to the arteries, in 
cases in which this organ, being hypertrophi- 
ed, is agitated by tumultuous and very much 
accelerated movements ; the existence of the 
bellows blast in the vessels which transmit 



72 PATHOLOGIC PHENOMENA IN 

the blood from the uterus to the placenta, 
as lately discovered by M. Kergaradec. 

2d , The noise of the rasp or file, of which the 
denomination gives an exact idea, which it is 
impossible to mistake when once it has been 
heard, may, like the bellows blast, accompany 
the contraction of any of the parts of the 
heart; but it is not intermittent like that, its 
strength alone varies; once developed it 
ceases no more. M. Laennec regards it as 
a certain sign of contraction of the orifices of 
the heart by ossifications, vegetations, or 
other cause. The period of the contraction, 
and the place in which it takes place, indicate 
the orifice affected. Does not the possibility 
of producing a very similar noise in a person 
subject to the bellows blast, by pressing on 
an artery with a certain force, appear to an- 
nounce that this is but a modification of the 
other, owing to a more marked state of 
spasm caused and maintained by an obstacle 
more difficult to overcome and always equal- 
ly resisting? 

3d, The sound resembling the cracking of 
new leather has only once presented itself to 
our observation; it was in a man who was 



DISEASES OF THE HEART. 73 

carried off by a chronic pericarditis. The 
sound lasted during the first six days of the 
disease, and disappeared as soon as the local 
symptoms announced a considerable effusion 
into the pericardium. M. Devilliers, inter- 
nal pupil at the Hospital Saint Antoine, 
observed it at the same time in the case of 
a man, who, from other symptoms, seemed 
to suffer from pericarditis. He was then 
ignorant that this phenomenon had already 
been observed in this affection, and did not 
found his diagnostic upon it. The patient 
went away after a tolerably long residence 
in the hospital. He presented himself again 
without having experienced any relief from 
the mode of treatment made use of. It is to 
be regretted; that if the patient has died, the 
diagnostic has not been verified by inspection. 
A second time M. Devilliers had an oppor- 
tunity of examining the dead body of a man 
who had presented this noise during the 
whole time of his abode in the hospital. He 
discovered a chronic pericarditis, which had 
produced thick false membranes and numer- 
ous vegetations over the pericardium and 
heart. There were only a few adhesions 
8 



74 PATHOLOGIC PHENOMENA IN 

between this organ and its envelope, and the 
sac of the pericardium did not contain a drop 
of serous liquid. Perhaps this noise may be 
a constant symptom of pericarditis before the 
occurrence of effusion into the serous en- 
velope of the heart, a fugaceous symptom, 
when the disease terminates in a few days ; 
of longer duration, when it is chronic. 

Rhythm. The changes in the rhythm of 
the heart's pulses are not very rare ; but for 
want of sufficient observations, we have not 
been able to convert them into diagnostic 
signs. 

They often accompany an hypertrophy, a 
dilatation of the heart, or the contraction of 
its orifices, during the whole duration of the 
complaint; they often manifest themselves 
also only in the later stages of these affec- 
tions ; at other times these lesions produce 
death, without the rhythm of the pulsations 
having been irregular. 

We shall consider the alterations of the 
rhythm; 1st, Relative to the respective 
duration of the contractions of the auricles 
and vetricles; 2d, Relative to their succes- 
sion. 



DISEASES OF THE HEART. 75 

1st. The alterations of the rhythm rarely 
depend on the duration of the auricular con- 
tractions ; they are usually owing to the in- 
creased length or'the shortness of the ventri- 
cular contractions, and then it is the period 
of repose which is increased or diminished. 
The first of these alterations, that which con- 
sists in the prolongation of the ventricular con- 
traction, is observed in hypertrophy, and is the 
more evident as the disease is more marked. 
The second, that in which there is greater 
rapidity of contraction, coincides with differ- 
ent states of the pulse, swiftness, rarity, and 
furnishes no data upon which we can found 
our diagnostic of diseases of the heart and 
lungs. ^^ 

2d. These alterations, considered as they 
relate to the succession of the pulsations, 
have been sufficiently often observed; they 
are usually transitory, and rarely attend more 
than two or three complete contractions of 
the heart. 

Thus sometimes the contraction of the 
auricle anticipates that of the ventricle ; at 
others, that of the ventricle anticipates the 
auricular contraction; or again, a contraction 



76 PATHOLOGIC PHENOMENA IN 

of the ventricle is followed by many succes- 
sive, rapid, as it were, convulsive contractions 
of the auricle, which, taken together, do not 
exceed the duration of an ordinary contrac- 
tion. 

The greater part of these anomalies do not 
produce any sensible change in the state of 
the pulse, and are not constantly met in any 
of the diseases of the heart. 

In the midst of a series of contractions 
equal to each other, we often observe many 
shorter, more lively beats, after which the 
heart returns to its natural rhythm. 

At other times, after a series of regular 
pulsations, the heart seems to stop, and re- 
main for a very long time in a state of repose. 
These kind of intermissions, observed in an 
adult, are always the sign of an affection of 
this organ. 

In line, in some more rare cases the swift- 
ness and irregularity of the contractions are 
such, that it is impossible to analyze them. 
In this case we may pronounce with certainty 
that there exists a disease of the organ. 

We see from this explanation of the 
pathologic phenomena furnished by the heart. 



DISEASES OF THE HEART. 77 

that there are only two, impulse and sound, 
which become certain signs of lesion of 
different parts of this organ; that all the 
others drawn from the rhythm, bellows blast, 
and rasping sounds, &c. have not been suffi- 
ciently often observed to enable us to say 
what alterations they indicate. But I doubt 
not that attentive observation of those dis- 
eases, and their 'daily observation with the 
cylinder, may one day furnish the information 
now wanting, and very soon render the di- 
agnosis of these affections as precise and 
easy as most of the other diseases of the 
thorax. ► 

Art. V.— Of Mensuration. 

This mode of inquiry consists in measuring 
one side of the chest and comparing it with 
the opposite side. The contraction or ex- 
pansion would not be evident, if both sides 
were affected at once ; so this examination 
can only be comparative. 

In some diseases, mensuration affords a 
valuable sign to assist the diagnosis, but is 
not sufficient alone to establish it. 
*8 



i H OF MENSURATION IN 

In reality, most m >ide 

more developed than the left : a great num- 
ber exhibit slight alterations in the form? 
of this cavity, resulting from their disposition 
to rickets in early infancy; it is therefore 
rlook vei 
Gist glance e atient seems to 

nt a dilatation or contraction- and with- 
out the assistance of mensuration, this am- 
>n would see ire. 

In procc ling to this mode of examinat: 
the patient is to be seat 

straight, and the upper limbs raised 
hanging a: ::i e t: *. but 

always in :_:e -~ :u 

state of contraction or of relaxation of the 
muscle- varies their projection, and may 

The half circumference of the - to 

be measured by placing one end of a cord* 

- spinous processes oi the vertebrae, 
and carrying the other round to the centre oi 
the sternum: then, without quirting this point. 

* A r: >-iuated mnawi , in i ndem wmk asn mmi 
in ladies' workboxes, is much more convenient. — Ed. 



DISEASES OF THE CHEST. 79 

bringing the cord round the other side to the 
spinous processes again, in the same direction 
and at the same height. 

It would perhaps be better to surround the 
whole chest with a cord, and then to fold this 
exactly in the middle ; it would then give 
the measure of the extent that each side of 
the chest ought to have, with which we 
should proceed as above directed. This 
method of inquiry furnishes only two signs, 
dilatation and contraction. 

Enlargement is always attended with 
flattening (redressement) of the ribs, widen- 
ing of the intercostal spaces, and more or 
less complete immobility of the enlarged 
part ; I say of the part, for this morbid en- 
larging may be of a whole side, or only of a 
part of one. Every effusion into the cavity 
of the pleura, at all considerable, necessarily 
produces dilatation. 

The contraction is accompanied also with 
change in the direction of the ribs ; they are 
more oblique, little or not at all moveable ; 
the intercostal spaces are narrower, some- 
times almost effaced ; like the dilatation, 
it is total or partial, but it occupies a whole 



80 OF MENSURATION, &C. 

side oftener than -this. Persons who present 
this alteration have a peculiar carriage, well 
described by M. Laennec, by which it may 
be guessed at the first glance. * The shoulder 
is depressed, the side of the chest shorter and 
flatter, the flank hollow, the pectoral muscles 
wasted, the head somew T hat inclined towards 
the contracted side. In most, the vertebral 
column preserves its natural rectitude ; in a 
few it bends. This contraction is always the 
consequence of an intense pleurisy, accom- 
panied with an abundant effusion of a liquid 
which has been absorbed. I think I have ob- 
served, in some cases of phthisis, a flattening 
at the summit of the chest beneath the clavi- 
cles, and that in those cases there was a very 
strong and close adhesion between the 
pulmonary and costal pleura, in the whole 
extent of space corresponding to the con- 
traction. 

* See plates 3d & 4th. 



OF SUCCUSSION. 81 

Art. VI. — Of Succussion. 

This mode of inquiry, of which Hippo- 
crates is agreed to have been the first pro- 
poser, consists in giving the trunk one or 
more abrupt rapid shakes, to produce the 
fluctuation of a liquid suspected to exist 
within the chest, and to assure ourselves of 
its presence and quantity. The shake need 
not be violent: a slight agitation is sufficient. 
This shake communicated suddenly to the 
liquid, causes a sound quite similar to that of 
shaking a bottle half full. It is needless to 
say, that this noise cannot exist if there is 
not at the same time air or gas, and liquid 
effused. The chest is always exactly filled, 
if it is the lung which occupies the portion 
not filled up by the effused liquid, and this 
cannot thrust it back to produce the sounding 
shock. If the gaseous effusion be in too 
great or too small quantity, succussion affords 
no satisfactory result. The two effusions 
must be in certain proportions. 

When this sound exists, it cannot be con- 
founded with any other ; I do not think 
that the fluids contained in the stomach can 



82 OF SUCCUSSION. 

give rise to it. Besides, it will always be 
easy to recognise with the cylinder the spot 
in which it occurs. The patients are often 
the first to advertise you of its existence ; 
they hear it at every stir ; the ear is usually 
sufficient to recognise it. 



PART. II.— CHAP. 1. 



Of Diseases of the Pleura and Lung. 

The five methods of investigation just ex- 
plained, are all generally of real utility ; and 
we shall see that each is successively called 
upon to furnish signs peculiar to a disease ; 
that in most cases they afford a mutual and 
necessary aid ; and that in adopting only one, 
even the most perfect, to the exclusion of the 
others, we expose ourselves to frequent mis- 
takes. 

If it were necessary now to class them ac- 
cording to their usefulness, we should not 
hesitate to put auscultation in the first rank ; 
after it percussion, succession, mensuration, 
and last, the examination of the thoracic 
movements. 

There is no disease of the chest in which 
auscultation does not furnish some sign. 



84 MODES OF EXAMINATION 

Among these some are sufficient alone to 
characterise the complaint ; thus the differ- 
ent kinds of rattle in catarrh, and in peripneu- 
mony ; haegophony in pleuritis ; pectoriloquy 
in excavations of the lung ; the metallic tink- 
ling in pneumo-thorax. Others, though few- 
er, are common to many diseases ; then aus- 
cultation becomes insufficient, even deceptive, 
and we must have recourse to another method. 

Percussion is the method which gives most 
aid to auscultation. It unites with it to 
strengthen the diagnosis of the first mention- 
ed affections, and in others prevents the er- 
rors which might follow the use of the cylin- 
der alone. Thus it establishes the distin- 
guishing character of peripnemony in the sec- 
ond stage from emphysema of the lungs, 
pneumo-thorax, and emphysema, slight oede- 
ma, and the first stage of peripneumony. 

Succussion gives the pathognomonic sign 
of pneumo-thorax with effusion. Mensura- 
tion gives one of the constant characters of 
empyema, which can sometimes be distin- 
guished by this alone from hepatization of the 
lung. 



IN DISEASES OF THE CHEST. 85 

The observation of the movements of the 
chest furnishes indications of the intensity, 
extent, and sometimes of the nature of cer- 
tain affections ; and further, a constant symp- 
tom of acute inflammations of the thoracic 
organs. 

Who does not know that in these affec- 
tions the first phenomenon which catches the 
eye is the immobility of the whole or part of 
one side of the thorax ? Pain in this case 
destroys the simultaneous action between the 
symmetric portions of the chest. What the 
will cannot effect, nature does unknown to us, 
by the simple automatic effect which leads us 
to withdraw ourselves from the feeling of 
pain. We see from what has just been said, 
that in assigning a place to each mode of 
inquiry, according to its utility, I am far from 
excluding any of them. 

In a materia medica we thus class medi- 
cines of the same order according to their de- 
gree of energy, without meaning that the 
strongest should make us reject the weaker. 

I shall divide diseases of the thorax into 



86 DISEASES OF THE CHEST. 

those which affect the respiratory organs and 
those which affect the heart. 

It is necessary to adopt an order for the 
explanation of the diseases of the lungs. To 
preserve the connexion and unity of my 
work, I have assumed as a basis that which I 
have followed in making known the phenom- 
ena recognised by the cylinder. This meth- 
od has appeared to me, besides, to unite the 
advantage of proceeding from simple to com- 
pound, in the application of the different 
stethoscopic phenomena to the diagnosis of 
diseases. 

I shall first make mention of the affections 
which the examination of the respiration 
makes known, and then those in which we 
must join to it the examination of the voice. 
To this first division I refer pleurodynia, pul- 
monary catarrh, apoplexy, oedema, and em- 
physema of the lung, pneumonia, hydro-tho- 
rax, and empyema ; to the second, pleurisy, 
pulmonary phthisis, gangrene of the lungs, 
and pneumo-thorax. 



DrSEASES OF THE CHEST. 87 

Art. I. — Of Pleurodynia *. 

I speak here of this affection, because I have 
observed some cases in which, though slight 
and of little importance, it has given rise to 
the belief in the existence of a severe disease 
of the lung, or of the pleura. 

In fact, when the muscular pain is violent, 
the ribs which correspond to all the diseased 
part remain immoveable in the actions of respi- 
ration ; it becomes then more or less incom- 
plete. 

Percussion returns a dull sound, either be- 
cause the pained muscles cannot be stretch- 
ed, or that the cause which has produced the 
pleurodynia has also caused a tumefaction of 
the fleshy covering of the chest. The respi- 
ratory murmur is weak in a greater or less 
extent, or wholly absent. 

These symptoms are also common to 
pleurisy and pneumonia. When treating of 
these diseases we shall find the differences 
which distinguish them. 

* This is usually termed by us, false pleurisy. It is 
a rheumatic affection of the membranous part of the 
thoracic parietes. — Transl. 



88 DISEASES OF THE CHEST. 

Art. II. — Pulmonary Catarrh*. 

In bronchitis, the examination of the move- 
ments of the chest furnishes few important 
signs ; the respiration is frequent, quick, 
small, unequal, irregular ; but these altera- 
tions appertain equally to many other diseas- 
es. They can only concur in indicating the 
degree of intensity and the extent of the ca- 
tarrh. The resonance of the breast is natu- 
ral, and the most severe catarrh rarely causes 
more than a slight obscurity of the murmur. 

Mensuration and succussion give no infor- 
mation ; there only remains the stethoscope ; 
but the signs it furnishes are truly pathog- 
nomic ; they vary as the catarrh is dry or 
moist. In the dry catarrh we observe weak- 
ness, or even absence in the respiratory mur- 
mur in parts of the lung of greater or less ex- 
tent ; but these change every moment, and 
during the course of a short examination, may 
occupy different points in turn, so that the 
murmur may become distinct where it was 
absent, and absent where it had just before 
been clearly perceived. 

* Bronchitis. — Transl. 



DISEASES OF THE CHEST. 89 

This weakness of the respiratory murmur 
is very often accompanied with the dry, so- 
norous, or the sibilant rattles. The first, lit- 
tle variable ; the second, very much so, disap- 
pearing for a longer or shorter time after the 
effort of coughing, or even without any evi- 
dent cause ; returning abrubtly, assuming an 
increased intensity, or losing that which it had 
at first. Sometimes, however, both are con- 
stant, intense, and occupy the greatest part 
of the organ : the catarrh is then extensive 
and violent. 

In the humid catarrh the same phenomena 
may exist, but they are then usually attended 
with a third, the mucous rattle ; or this alone 
is heard, and is sufficient to characterize the 
complaint. Less frequently varying its situa- 
tion than the hissing rattle, the mucous rattle 
presents shades, either in force, frequency, or 
extent, which make known the different de- 
grees of the catarrhal affection. Catarrh may 
be easily confounded with emphysema of the 
lung and pulmonary phthisis. (See Emphy- 
sema and Pulmonary Phthisis.) 



90 DISEASES OF THE CHEST. 

Art. III. — Pulmonary Apoplexy*. 

The attack of this disease being usually 
sudden, we observe all at once a great degree 
of dyspnoea ; the movements of the breast 
are accelerated, hurried; there is no longer 
any order in their succession, the most strik- 
ing irregularity accompanies them ; they are 
unequal, intermittent, large, and small, by 
turns, as if convulsive ; in fine, the patient is 
in that state, termed orthopnea : he is suffo- 
cating, and all the thoracic movements ex- 
press the anxiety caused by this uneasy sen- 
sation. The breast however remains as 
sonorous as before the attack, but the res- 
piratory murmur is altered. The crepitating 
rattle develops itself in more or less numer- 
ous a«d circumscribed points of the lung. 
The spaces between these still present a per- 
fect, and even puerile respiratory murmur. 
At the end of a longer or shorter time it 
ceases to be heard ; an abundant mucous rat- 
tle in large bubbles, succeeds to it, indicating a 
copious exhalation of blood into the air cells 
and bronchia, occupying very soon the whole 

* Haemoptysis. — Transl. 



DISEASES OF THE CHEST. 91 

lobe or affected lung, and the bloody expec- 
toration soon confirms the diagnostic already 
pointed out by those phenomena. 

In the second stage of pulmonary apoplexy, 
the sound of the chest (on percussion) be- 
comes obscure. 

In the first, it may impose on us for a 
commencing pneumonia ; in the second, for 
a catarrh, if it is chronic, and that the spitting 
of blood, as is generally the case, is not con- 
stant. I have lately observed two cases of 
this slow apoplexy of the lungs. They were 
both mistaken for some days. The distin- 
guishing signs of those two affections can 
only be known by commemorative circumstan- 
ces, and a certain diagnosis will always be 
difficult. 

Art. IV. — (Edema of the Lung. 

Respiration usually slow, but laborious, 
difficult ; from time to time orthopnoea, res- 
piration always complete. 

Sonorousness, natural or dull, but of both 
sides at the same time. This disease rarely 
occupies a single lung. Respiratory murmur 



92 DISEASES OF THE CHEST. 

scarcely distinct, marked in almost the whole 
viscus, but chiefly in the back and inferior 
parts, by a sub-crepitating rattle, slight and 
energetic, but constant in its existence ; the 
respiration sometimes puerile in a small ex- 
tent of the upper part bf the organ. Such 
are the symptoms of oedema of the lung. 

The diagnosis of this complaint is easy, 
when the disease is severe ; but difficult, 
when it is slight ; impossible, when it is com- 
plicated with pneumonia or emphysema 
of the lungs. It may be confounded with 
pneumonia (See Pneumonia). The nature 
of the rattle, and particularly the general 
symptoms, distinguish it from catarrh. 

Art. V. — Emphysema of the Lung. 

This complaint, among the number of 
those which have been long confounded 
under the name of asthma, is characterized 
by an extreme dyspnoea, increasing by par- 
oxysms, without any regularity in their re- 
turn or duration, and exasperated by the 
most trifling cause. The movements of the 
chest are extensive, but performed with little 



DISEASES OF THE CHEST. 93 

regularity, habitually unequal ; inspiration 
is usually short, rapid, abrupt, and high ; the 
expiration gradual and incomplete : the dif- 
ference between the duration of those two 
movements makes the respiration seem in- 
terrupted. In the paroxysm it becomes con- 
vulsive. 

On percussion, the chest yields a more 
than naturally clear sound, whatever ma) be 
the degree of plumpness of the patient. 

But tlii erated resonance is not equal 

at all points because the disease rarely occu- 
pies a whole lung. IT the affection is double, 
it is difficult to appreciate this increase of so- 
norousness of the thorax, and when the em- 
physema exists only on one side, it becomes a 
deceptive sign, the \;ilue of which can onlj 
be judged by auscultation. 

In fact, the murmur of respiration is ?erj 
weak or wholly absent in all the points at- 
taeked In emphysema : a slight sibilant rat- 
tle similar to the clicking of a small valve, or 
a sonorous rattle imitating the cooing of a 
dove, is heard in deep inspirations, and some- 
times also in expirations. The contrast of 
this greater resonance (or hollowness) of the 



94 DISEASES OF THE CHEST. 

thorax, with the diminution or absence of 
the murmur, forms a characteristic symptom 
of this disease. It is true that these charac- 
ters of the respiration and the existence of 
the rattle are inconstant and variable ; but 
they always remain a long time, and their 
changes are only momentaneous. 

When the complaint is chronic and very 
extensive, another sign drawn from the men- 
suration may be added to those just enu- 
merated, the dilatation of the side affected; 
and if the affection is on both sides, the al- 
most cylindrical form of the chest projecting 
behind and before. Emphysema, sometimes 
distinguished with difficulty from pulmonary 
catarrh, may also be taken for a pneumo- 
thorax without liquid effusion. 

Let us first explain how it differs from 
catarrh. In catarrh the suspension of the res- 
piratory murmur is of short continuance in the 
same point; its return is sometimes marked 
by a strong and even puerile respiratory mur- 
mur; a frequent rattle attends it. 

In emphysema, the suspension of respira- 
tion at the same point is longer, sometimes 
even permanent ; when it ceases, the sound 



DISEASES OF THE CHEST. 95 

always remains more feeble, particularly if 
the complaint be ancient. The hissing rattle 
is rare, and badly characterized ; the sono- 
rous rattle, imitating the cooing of the dove, 
is constant, and almost never determined by 
a simple catarrh. 

Besides, in this last affection, the move- 
ment of the sides is free ; the respiration pre- 
sents no constant inequality ; the chest pre- 
serves its natural capacity and hollow sound. 
In emphysema, one side is often less movea- 
ble than the other ; inspiration is always very 
short, relative to expiration ; the chest di- 
lates, and acquires a tympanitic resonance. 

It is scarcely of use to say that percussion 
establishes at once the difference between 
emphysema and the other diseases of the 
chest in which respiration appears to the cyl- 
inder more feeble or absent : I only except 
pneumo-thorax. (See Art. Pneumo-thorax.) 

Art. VI. — Pneumonia. 

To establish the signs afforded by the five 
modes of inquiry in pneumonia firmly, we 
must distinguish three periods in this com- 



96 DISEASES OF THE CHEST. 

plant. We may perhaps admit even a fourth, 
founded upon the observations related above ; 
but it appears to me very doubtful that in all 
cases the respiration assumes the puerile and 
superficial character in parts about to be at- 
tacked with pneumonia. New observations 
will soon teach us what degree of confi- 
dence this phenomenon merits. 

In the first stage of pneumonia, the respi- 
ration is high, small, accelerated, unequal, 
difficult, sometimes laborious. It becomes 
abdominal, if both sides are at the time affect- 
ed in a high degree. 

The chest sometimes sounds as in health : 
but its sonorousness is often diminished, and 
even completely lost in a more or less consid- 
erable extent, very exactly limited to the part 
diseased. 

The respiratory murmur is feeble, in all 
parts where the sonorousness is diminished 
scarcely distinct, or sometimes covered by a 
crepitating rattle ; at one time dull, at an- 
other sonorous enough, and the presence of 
which indicates both the nature of the altera- 
tion and the whole extent it occupies. The 
respiration then often becomes puerile in the 



DISEASES OF THE CHEST. 97 

Other lung, and in all the parts of the affected 
lung yet remaining healthy. 

These phenomena very soon change. If 
the disease terminates by resolution, the cre- 
pitating rattle diminishes in intensity every 
day; the murmur of respiration approaches 
more and more to the natural state ; the move- 
ments of the chest resume their rhythm, their 
extent, and simultaneousness ; the sound re- 
turns, and the mucous rattle, in a greater or 
less degree, indicates the change of expecto- 
ration. 

On the contrary, if the lung passes to the 
state of hepatization, the alteration of the 
movements of the thorax continue, the sound 
becomes completely dull, the crepitating rat- 
tle ceases, but the respiratory murmur does 
not return ; the smallest quantity of air can- 
not penetrate the hardened tissue of the lung. 
Respiration is wholly absent, or if heard, is 
so only in the vicinity of the large bronchial 
tubes ; it is then tracheal, cavernous, and of- 
ten very loud ; the hollowness of the voice 
red6ubles in all the affected parts ; often in 
induration of the upper lobe even a true pecto- 
riloquy begins to complicate the diagnosis, 
10 



98 DISEASES OF THE CHES1. 

and throw doubts upon the nature of the af- 
fection. We must have recourse to the com- 
memorative circumstances, to the general 
symptoms, to prevent our supposing the ex- 
istence of pulmonary phthisis. 

When the disease is of small extent, nature 
and art exert their powers, and are often at 
this period crowned with success ; the disease 
retracing its steps by the same way it ad- 
vanced, presents in turns and in inverse order 
the phenomena before observed. But if the 
complaint continue its progress — if the sup- 
purative process seizes upon the pulmonary 
tissue, the movements of the chest become 
smaller and smaller, feeble and more difficult; 
to the first causes of their alteration general 
debility is added. The sound remains dull ; 
a large bubble mucous rattle is first developed 
in isolated points, then in all the morbid part. 
It soon degenerates to the gurgling rattle ; the 
pus collected in an abscess bursts into the sur- 
rounding bronchia ; a communication is form- 
ed between these tubes and this accidental 
cavity, and pectoriloquy manifests itself, at 
first obscure, whatever may be the point the 
disease occupies. 



DISEASES OF THE CHEST. 99 

We see, from this abridged sketch, that 
each stage has very striking characters; and 
that if we have been called in at the com- 
mencement of the complaint, and have been 
able to follow the progress of the disease, step 
by step, it is easy to predict, in case of death, 
the extent and degree of lesion that will pre- 
sent itself. It is not so if we see the patient 
for the first time in the second state, when 
the lung is hepatized. In fact some ribs are 
immoveable, the sound is dull, the respira- 
tion absent; but those symptoms are com- 
mon to empyema and hydro- thorax. Here 
the five modes of inquiry are insufficient, and 
we must seek for information in the amnestic 
signs and progress of the disease. Percus- 
sion and auscultation could not prevent an er- 
ror always disagreeable, sometimes fatal. 

In the third period, that of suppuration, it 
is difficult to guard against a mistake, less 
unpleasant indeed, but which may compro- 
mise the reputation of the physician. 

The cavernous respiration, the gurgling, 
and pectoriloquy exist, and the general symp- 
toms are nearly those of pulmonary phthisis. 



100 DISEASES OF THE CHEST. 

As to the chronic pneumonia, after a vom- 
ica has formed and burst into the bronchia, 
we must apply to it what we have said of 
the second degree, that of hepatization, or of 
the third, that of suppuration. 

It remains to say what signs distinguish 
pneumonia from pleurodynia, from the first 
degree of pulmonary apoplexy, and from oede- 
ma of the lung. The crepitating rattle in 
the first state ; the dull sound on percussion 
and perfect absence of respiratory murmur in 
the second ; the dulness, mucous rattle, and 
pectoriloquy in the third stage, distinguish 
pneumonia from pleurodynia. In most cases 
percussion would prevent our confounding 
this disease with pulmonary apoplexy, if the 
examination of the movements of the chest 
did not already afford a good diagnostic dif- 
ference. In fact, in pulmonary apoplexy the 
respiration is always complete ; it is usually 
incomplete in pneumonia. The sound is al- 
ways more or less obscure, often wholly ab- 
sent, in the first stage of pneumonia when 
the crepitating rattle exists ; it remains clear 
in the first stage of pulmonary apoplexy. 
The crepitating rattle is seldom widely spread 



DISEASES OF THE CHEST. 101 

in pneumonia ; it is so usually in apoplexy. 
The mucous rattle suddenly succeeds the 
crepitating in the latter. 

In pneumonia the absence of all respiratory 
murmur exists sometime between the mo- 
ment in which the crepitating rattle ceases, 
and that in which the mucous commences. 

It is the same with oedema of the lung. 

Art. VII. — Empyema and Hydro-thorax. 

I join those two complaints together, be- 
cause their symptoms are absolutely the 
same, and I refer what I have to say of them 
to the article of Pleurisy. 

Art. VIII. — Pleurisy. 

The signs afforded by the different modes 
in this disease, vary according to their being 
considered at the commencement, or after 
effusion has taken place. 

In the commencement, that is before a 
serous or plastic liquid has been accumula- 
ted between the pleura and the lung, the 
movements of the thorax are enfeebled or 
almost wanting on the affected side. We 
*10 



102 DISEASES OF THE CHEST. 

have daily opportunities of observing that 
the ribs of the affected side alone are im- 
moveable, while the others continue to move. 
Respiration is frequent, particularly if both 
sides are affected at once, quick in inspira- 
tion, interrupted, irregular. These charac- 
ters continue during the whole acute stage 
of the complaint. 

Percussion is^painful, but gives the same 
results as in the sound state. 

The respiratory murmur is enfeebled, but 
pure, if the disease be not complicated; the 
capacity of the chest is not augmented. 
Finally, the symptoms are as in pleurodine — 
a disease it is impossible to distinguish from 
the commencement of pleurisy, except by 
the general symptoms. 

When the effusion has taken place, and is 
in small quantity, the resonance usually be- 
comes obscure in the lateral and posterior 
inferior parts, or in any point of the thorax, 
if the disease be circumscribed and an an- 
terior pleurisy has produced adhesions suffi- 
cient to confine the liquid. 

The cylinder applied along the spinal 
edge of the scapula, towards its point or its 



DISEASES OF THE CHEST. 103 

outer edge, or in fine in any other place, even 
under the clavicles, according to the extent of 
the effusion, or the point it occupies, renders 
evident that sharp, tremulous, jerking voice, 
called by M. Lasnnec haegophony. The res- 
piratory murmur is absent or scarcely dis- 
tinct, in all that part in which the sonorous- 
ness is altered. It becomes sometimes puerile 
in the upper parts of the lung. 

If the effusion is very considerable in the 
beginning, or becomes so in the progress of 
the affection, the sound becomes wholly flat, 
the hsegophony disappears, the respiratory 
murmur is no longer audible, unless short 
adhesions retain parts of the lungs near the 
ribs, and prevent them from being thrust 
back. The intercostal spaces widen, rise 
to the level of the ribs : these become flat- 
tened ; the affected side enlarges, it becomes 
unfit for respiration, and its immoveability 
contrasts with the greater mobility of the 
opposite one on which side the respiration 
acquires the puerile character. 

If absorption of the liquid takes place, 
haegophony reappears when the quantity is 
reduced to that necessary to the production 



104 DISEASES OF THE CHEST. 

of the phenomena: it then gradually di- 
minishes as the quantity lessens, and finally 
disappears altogether when the absorption is 
completed. However, the sound still remains 
a long time flat, and the respiration absent or 
feeble ; the ribs fall, the intercostal spaces 
sink, are effaced; the chest contracts, and 
that side never assumes either its former 
volume or mobility. 

The resonance increases, and the respira- 
tory murmur is heard with any force only 
when the pseudo-membranes have been con- 
verted into an organized tissue, similar to 
cellular membrane, fibro-cartilage, or bone. 
No disease can be confounded with pleu- 
risy, so long as hsegophony exists, except 
commencing hydro-thorax. 

This phenomenon is always a pathognomo- 
nic sign of these two affections ; the other local 
and general symptoms serve to distinguish 
them. 

But when the effusion is copious and the 
disease chronic, if we have not attended to its 
progress, we may take pleurisy for a hydro- 
thorax or chronic pneumonia, and reciprocally 
these affections for a pleurisy. 



DISEASES OF THE CHEST. 105 

The anamnestic signs and the general 
symptoms alone can establish the distinction ; 
this is the more important, as little can be 
done for chronic pleurisy, while powerful 
and efficacious remedies remain for hydro- 
thorax and pneumonia. The operation for 
empyema is the only relief in chronic pleu- 
risy, and would have more success without 
doubt if earlier performed. 

However, the dilatation of the thorax, the 
perfect immobility of the ribs, seem to me 
not to exist in chronic pneumonia, and es- 
tablish constant differences of character, un- 
less the diseased side, having been before 
affected with contraction, has been incapable 
of enlarging. 

As to the possibility of confounding chronic 
pleurisy and pulmonary phthisis, I think that 
even when there is not pectoriloquy, there 
are other characters sufficiently distinguish- 
ing to render this mistake hereafter impossi- 
ble (avoidable, Ed.); and even when they 
are complicated, it is often easy to dis- 
tinguish them from each other. 

The difference between pleurisy and pleu- 
rodyne is easily laid down, In pleurisy, 



106 DISEASES OF THE CHEST. 

when we observe the respiration incomplete 
the resonance obscure, and the murmur 
absent or feeble, there will be haegophony at 
the same time; this phenomenon never exists 
in pleurodynia. If the effusion was copious 
enough to destroy the haegophony, there 
would be dilatation. Moreover, the error in 
any case cannot exist long. 

Art. IX. — Pulmonary Phthisis. 

To lay down the semeiology of pulmonary 
phthisis the more clearly, we shall admit it 
to have three stages, although this complaint 
is seldom constant in its duration, and so ob- 
scure in its progress as rarely to favor 
this division. 

The first of those periods, that in which 
an inconsiderable number of tubercles are 
developed in the lung, presents on examining 
the local phenomena and the general symp- 
toms, only the appearance of a catarrh of 
greater or less severity ; it is sometimes con- 
cealed from observation, and does not seem 
to exist. 

In the second stage, the tubercles are al- 



DISEASES OF THE CHEST. 107 

ready in sufficient numbers to stifle, as we 
may say, the tissue of the organ in those 
places where they are most frequently obser- 
ved to accumulate, and give rise to phe- 
nomena, insufficient to enable us to say with 
certainty that the disease exists, but enough 
to make us suspect it. 

Finally, in the third, the melting, the 
softening, and evacuation of the tubercles, 
gives place to a phenomenon which is always 
a certain sign of this affection and the shades 
of which point out its extent and its inten- 
sity. 

The change in the movement of the thorax 
are extremely variable in this tedious and 
melancholy complaint. They may be all 
met with during its progress, but are never 
of great use in the diagnosis. 

In the second stage, the upper part of one 
side of the chest frequently returns a flatter 
and more obscure sound than natural, on per- 
cussion. The stethoscope applied to this spot 
makes known a feebleness, or even complete 
absence of the respiratory murmur, generally 
in an extent rather limited; the voice re- 
sounds with more force under the instru- 



108 DISEASES OF THE CHEST. 

ment; but these symptoms only become 
signs of the complaint when they exist on 
one side alone, and are constant; it is only 
the comparison between the healthy and the 
diseased side which shows their value. 

The sound on percussion very soon re- 
turns, and sometimes acquires even more 
intensity, or it loses still more of its distinct- 
ness, and from being obscure as before, be- 
comes quite dull. 

Pectoriloquy becomes at first doubtful, 
but does not delay long to acquire its greatest 
perfection, and ends by being again only im- 
perfect, if the disease, continuing its pro- 
gress, produces vast excavations. The phe- 
nomena produced by the catarrh are extended 
and aggravated from day to day, and con- 
tinue to the moment of death. 

If in all cases those two very striking 
periods, and this succession of phenomena 
existed, phthisis would cease to be a dis- 
ease so often difficult to recognize ; but 
how frequently does it not happen, that 
patients fall before the softening and evacua- 
tion of the tubercles, even before their ac- 
cumulation has altered the sonorousness of 



DISEASES OF THE CHEST. 109 

the chest, or injured the perfection of res- 
piration. 

The melancholy information acquired try 
the cylinder is certainly precious ; but in 
most cases the disease is beyond the reach 
of art when it is discovered. 

Chronic pulmonary catarrh must then be 
always confounded with phthisis, so long as 
pectoriloquy, or the three phenomena men- 
tioned as signs of the accumulation of tuber- 
cles, do not exist *. 

Phthisis will also be confounded with acute 
or chronic pneumonia, occupying the upper 
lobe of the lung ; the distinguishing characters 
can only be found in the general symptoms 
and the appearance of the expectoration ; 
and these are but little to be trusted to. 

It will more rarely resemble emphysema 
of the lung, and percussion and the general 
symptoms will easily distinguish them. 

The dilatation of the bronchia, a common 
consequence of long-continued pulmonary 
catarrh, gives rise also to the phenomena of 

* The chief diagnostic symptom is the rattle which 
attends the catarrh. — Transl. 

11 



110 DISEASES OF THE CHEST. 

pectoriloquy. It is then impossible to avoid 
a mistake; time alone, and the progress of 
the disease, sometimes undeceive us. 

Art. X. — Gangrene of the Lung. 

This rather rare disease may affect the 
surface of the viscus ; it then occasions a 
pleurisy, with or without pneumo-thorax ; 
or it may develop itself in the centre of the 
organ. I have only twice had an opportunity 
of observing this mortal affection. The first 
time, I did not yet know the use of the cylin- 
der; and the second, the disease was ac- 
companied with pneumo-thorax of long stand- 
ing, with liquid effusion and bronchial fistula ; 
so that it was difficult, in the midst of the 
number of phenomena observed, to distin- 
guish those which belonged to the gangrene 
exclusively. 

But it is easy I believe to point out, from 
analogy, the symptoms this disease should 
present. In the first stage of the affection, 
they will often be similar to those of peri- 
pneumony or of a severe catarrh ; in the 
second, they will resemble those cf pulmo- 
nary phthisis. 



DISEASES OF THE CHEST. Ill 

The general symptoms, and more particu- 
larly the repulsive odour, and the appearance 
of the expectoration, will be sufficient in all 
cases, to prevent mistakes. 

This disease then has no symptom peculiar 
to it alone. 

Art. XI. — Pneumothorax. 

The signs of pneumo-thorax vary, accord- 
ing as it is with or without communication 
with the bronchia. In either case it may be 
simple, or complicated with liquid effusion. 

In the simple form, without bronchial 
fistula, the obstruction of the movements of 
the chest, and their alteration, is the same 
as in emphysema of the lung, sometimes 
even in a more marked degree. 

The side affected returns a hollow, tym- 
panitic sound, even when the thoracic walls 
have much thickness. Sometimes the lung 
is connected to the costal pleura at many 
points, by the cellular adhesions: then the 
sound nearly natural at those points, offers 
still more striking differences where there is 
no adhesion. 



112 DISEASES OF THE CHEST. 

The respiration is wholly absent in all the 
extent occupied by the gaseous effusion: it is 
scarcely evident even towards the root of 
the lung, between the scapula and the spine. 

This absence of the respiratory murmur is 
owing to two causes ; 1st, The thrusting back 
of the lung, by the gas collected within the 
pleura ; 2d, The presence of this gas itself, a 
bad conductor of so feeble a sound as that 
produced by the air entering the bronchial 
cells. 

Finally, the side occupied by the gas is 
usually dilated, and presents exteriorly the 
same peculiarity as in empyema. 

When the gaseous accumulation is pro- 
duced by a laceration on the lung, or the 
formation of a fistula, which opens at once 
into the bronchia and cavity of the pleura, 
there are joined to the preceding, new signs 
easily understood, and always pathogno- 
monic : these are metallic respiration, and 
metallic resonance. 

In fine, when the effusion is at the time 
liquid and gaseous, and the festulous commu- 
nication has taken place, besides the pre- 
ceding signs we hear the metallic tinkling, 



DISEASES OF THE CHEST. 113 

and succussion makes the agitation of the 
fluid within the chest evident; if there is no 
bronchial fistula, the two last phenomena 
alone are perceptible, to the exclusion of 
metallic respiration and resonance. 

In the cases of two-fold effusion, percus- 
sion furnishes important signs; it produces 
a clear sound in the upper parts, a dull one 
in the most depending ones: so that by 
varying the patient's position, we can alter 
the part occupied, by the clear sound, and the 
dull one. 

Percussion serves to distinguish this affec- 
tion in all cases from those in which the res- 
piration is not heard in a very extended 
space, and during a considerably long time. 

We can scarcely then confound it, except 
with emphysema of the lung ; but the chest 
rarely has so exaggerated a sound in this af- 
fection. The respiration is never completely 
inaudible ; it is always evident towards the 
root of the lung; it is accompanied with va- 
rious rattles, and reappears quickly enough, 
in parts where it has become inaudible. 



'11 



CHAP. II. 

On the Diseases of the Heart. 



Before commencing the investigation of 
the diseases of the heart, I may be permit- 
ted to say a few words upon the utility of the 
cylinder in these affections, and upon the real 
advantages to be derived from it in their 
treatment. 

I will first observe, that none of the other 
methods is applicable to the diagnosis of in- 
juries of the central organ of the circulation : 
that they only make known its complications, 
and only unmask the disease when it is be- 
yond the reach of art. I except however 
percussion ; but the cases in which it offers 
any advantages are extremely rare. 

Corvisart, whose name presents itself so 
naturally when we speak of diseases of the 
heart, had without doubt made great progress 



DISEASES OF THE HEART. 115 

in this mode of distinguishing the alterations 
which take place ; it did not seem likely 
that the eye of the physician could ever pene- 
trate more deeply into their progress, which 
is commonly so obscure, and in one day un- 
ravel symptoms the most difficult to recog- 
nize. In fact, this great observer, not con- 
tent with distinguishing active from passive 
aneurism, has pointed out particular charac- 
ters, drawn from the state of the face, its 
color, and the state of the pulse, which ena- 
ble us to predict with certainty, whether the 
disease occupies the right, or left cavities ; 
but all those symptoms only show them- 
selves when the disease is of long standing, 
and art nearly powerless to destroy it. Few 
men, besides, are possessed of the medical 
tact which Corvisart enjoyed in so high a de- 
gree ; and, spite of his labors, mistakes are 
still of daily occurrence, and even well-in- 
formed physicians mistake those diseases 
every day. 

The symptoms pointed out by Covisart, 
then, have the double inconvenience of being 
difficult to recognize, and of appearing too 
late. On the contrary, those afforded by the 



116 DISEASES OF THE HEART. 

cylinder show themselves from the com- 
mencement of the affection, and are detect- 
ed with facility by even the most unpractis- 
ed *. By a little practice he may even 
acquire such precision as to announce, with- 
out fear of being deceived, whether there be 
hypertrophy or dilatation ; if such or such 
a ventricle be diseased, if they are both so, 
and if the different orifices be free or con- 
tracted by ossifications, which we can rarely 
guess by any other means. 

Shall we be told that so minute an ac- 
quaintance with the state of the diseased part 
serves the treatment in no degree ; that it 
is but a useless display, embarrassing to the 
physician, and disagreeable to the patient ? 
But even were this the fact at present, who 
can answer that that which is now a super- 
fluity, when pathologic physiology is so little 
advanced may not afterwards become of real 
utility? Besides, has the merit of the dis- 

* This assertion is perhaps too hold ; since it is well 
known that persons of quick observation are liable to 
make mistakes before they acquire precision in the 
use of the instrument. — Ed. 



DISEASES OF THE HEART. 117 

coveries of the medical anatomists, who have 
described tubercles, scirrhus, medullary fun- 
gus, and melanoses been contested, although 
the practical physician can draw no advan- 
tage from this knowledge for the treatment 
of these diseases? 

Will the necessity for the cylinder be con- 
tested, if I prove that these affections never 
unmask themselves but when they are of long 
standing, and almost incurable, and that they 
have a first stage in which they necessarily 
escape us, and auscultation alone can enable 
us to recognize them ? To come to this re- 
sult, let us examine what takes place in these 
diseases ; and as it would be tedious to re- 
view them all, let us take hypertrophy for 
an example, affecting the left or right ven- 
tricle. 

What happens, when the left ventricle is 
hyertrophied ? 

The blood is pushed with more force into 
the arteries ; these vessels having thin and 
resisting w r alls cannot experience any violent 
lesion from this too energetic shock, even 
should the disease not develop itself slowly, 
and give them time to accustom themselves 



118 DISEASES OF THE HEART. 

to its first effect. The fatal influence is then 
borne upon the capillary system. This sys- 
tem, which is very much extended, and dis- 
posed so that the circulation may meet no 
obstruction, communicates freely with nu- 
merous vessels, which in the ordinary state 
contain no blood, but which numerous natu- 
ral phenomena demonstrate their disposition 
to admit, and the possibility of its circula- 
ting in them without danger. All this vas- 
cular network enters into the composition of 
organs, firm enough to support it, whose 
multiplied movements powerfully favor its 
circulation. The sanguineous capillary sys- 
tem empties into these multiplied canals the 
superfluity it cannot hold. 

The impulse of the blood, already weak- 
ened by the long passage it has already run 
in the arteries, loses still more of its force by 
dividing, and limits its effect to advancing 
the progress of the blood in the capillaries, 
and afterwards in the veins; so that a new r 
equilibrium, we may say, is established be- 
tween the arteries and the veins: all the or- 
gans are more supplied with blood, gorged, 
and the symptoms confine themselves to 



DISEASES OF THE HEART. 119 

those of plethora, without any one indicating 
the particular cause of this state of general 
turgescence. 

This first stage is entirely latent ; and the 
symptoms recognizable as signs of hypertro- 
phy of the heart, will only appear in the sec- 
ond stage, about to be considered. 

At the end of a longer or shorter time, 
according to the subject, some capillaries, 
weakened by this constant tension, this per- 
mament state of action, dilate and are ob- 
structed ; this takes place commonly in the 
lower extremities, in which many causes of 
dilatation act. The obstruction is propaga- 
ted slowly, nearer and nearer ; the first 
symptoms of serous cachexy appear in the 
extremities. The column of blood pro- 
pelled by the heart has already fewer out- 
lets ; they diminish still more every day. 

Very soon obstructed in its course, the 
capillary system offers a continually increas- 
ing obstacle to each wave sent to it by every 
contraction of the ventricle. This not being 
able to unload itself of all the blood it con- 
tains, ceases to admit all which the lungs trans- 
mit to it. The veins of that delicate organ 



120 DISEASES OF THE HEART. 

promptly experience the same alterations as 
the general capillary system. The catarrhal 
affection, concomitant of diseases of the 
heart, developes itself, and death delays not 
long his arrival, preceded by all the inci- 
dents which the simultaneous lesion of the 
heart and lungs can produce. 

In the commencement of this stage the 
complaint is already severe, and still the 
symptoms are but little characteristic. It is 
only towards the end, at a period near the 
conclusion of the disease, then necessarily 
fatal, that the combination of symptoms 
which denote it are developed, and manifest 
themselves evidently. 

In hypertrophy of the right ventricle, it is 
still more indispensable to employ a means 
which may make known the disease at the 
commencement ; for the first stage is very 
short, and the disease acts upon an organ the 
most essential to life, the texture and func- 
tions of which it quickly alters, In fact the 
column of blood, propelled by the hypertro- 
phied ventricle with too much force, strikes 
against arteries with thin coats, easily exten- 
sible. These arteries are very short, and 



DISEASES OF THE HEART. 121 

terminate in an excessively fine network, 
very near the point of departure of the 
blood, so that the shock has lost nothing of 
its force when it arrives there. This capil- 
lary system is plunged into a soft, vesicular 
organ, which lends it no support; it cannot, 
like the general system, subdivide itself, as 
we may say ; and its circulation is not for- 
warded by sufficiently numerous or power- 
ful movements. So unfavorably disposed to 
answer or yield to the increased force of the 
ventricle, these vessels soon dilate ; their 
tonicity is lost ; they become obstructed ; 
the blood stagnates in them, and opposes a 
daily increasing resistance to the column of 
blood circulating in the arterial trunks. The 
right ventricle ceases to admit all the blood 
brought to it by the veins ; local congestions 
form, both exteriorly and interiorly ; oedema 
develops itself in several parts ; the catarrhal 
and oedematous state of the lung has already 
long existed. 

However, this varicose state, as it may be 

called, obstructs the purification of the blood, 

the air can only act upon the smaller quantity 

now circulating in the lung ; the left ventricle 

12 



122 DISEASES OF THE HEART. 

receives little of it, and transmits little to the 
organs ; the general debility increases every 
day, and the exhausted patient sinks, after 
having experienced, but at an earlier period, 
the same affections as in hypertrophy of the 
left ventricle. 

We observe here, in the first stage, only 
an alteration of the lung, which is at first 
slight, and necessarily confounded with some 
other affection of that organ ; and when the 
local congestions and the oedema lead us to 
suspect the primitive affection, the secondary 
disease is already as much and more difficult 
and dangerous to cure. With what eagerness 
ought we not to embrace a method which 
furnishes certain data in such dangerous cases, 
at the only period in which it is possible 
to combat and overcome the disease ? 

These considerations prove the utility of 
the cylinder, particularly when the pheno- 
mena we observe can be referred to no w T ell 
known lesion ; they explain also the differ- 
ences presented by two similar affections oc- 
cupying different parts of the same organ, 
rpbus we see why bloodletting, which gives 
Bq piuch relief in thickening of the left ven- 



DISEASES OF THE HEART. 123 

tricle, produces little effect in that of the 
right : why in the first the catarrh develops 
itself later than in the second ; why oedema 
of the lung is more frequently and rather a 
disease of the right ventricle, than of the 
left ; why the expectoration of bloody sputa 
— not unlike the blood which escapes from 
varicose vessels — takes place oftener in the 
former than in the latter ; finally, why the* 
right ventricle constantly acquires less thick- 
ness than the left. 

We also easily explain the difference of 
countenance peculiar to each of these affec- 
tions, and the state of the pulse in both. 

I return to my subject, from which I have 
let myself be drawn so far, by the desire of 
proving the importance of auscultation in 
diseases of the heart. 

Considering the application of the steth- 
oscope to the diagnosis of these diseases, I 
shall divide them into those characterized 
by alteration of the shock, those known by 
the alteration of the sound, and those in 
which both have experienced alterations ; 
finally, I shall treat of aneurism of the aorta, 
and of pericarditis. Th's division compre- 



124 DISEASES OF THE HEART. 

hends neither raptures of the heart, nor its 
faulty degeneration, its induration, its inflam- 
mation, nor the diseases of the auricles. For 
want of observations, I am ignorant what 
signs the cylinder yields in those affections. 

Art. I. — Diseases characterized by alteration 
of the shock. 

Hypertrophy. The enlargement of the heart 
causes no alteration in the movements of the 
thorax, which is peculiar to it, or affording 
one of its signs. Those which we observe 
always depend on the state of the lung, which 
is readily affected in this complaint ; they 
generally consist in an habitual dyspnoea, in- 
creasing in paroxysms, carried at this time, 
and during the latter moments of life, to a 
state of orthopnoea, 

Percussion rarely furnishes any results ; 
however, in some cases of very severe hyper- 
trophy, the sound has been observed to be 
obscure or flat in the precordial region. 

The investigation by means of the cylin- 
der produces more certain and constant re- 
sults. The contraction of the ventricles gives 



DISEASES OF THE HEART. 125 

a strong noiseless impulse, prolonged in pro- 
portion to the extent of the hypertrophy, 
often limited to a space smaller than in the 
healthy state. Sometimes the pulsations are 
irregular, intermittent; most commonly their 
rhythm experiences no other alteration than 
an increased duration of the ventricular con- 
traction. Then that of the auricles takes 
place before that of the ventricles is finished ; 
it is short, attended with little noise, and for 
that reason scarcely sensible. 

These phenomena are perfectly distinct in 
all cases so long as respiration remains free, 
or is little disturbed. If the dyspnoea be- 
comes extreme, they often disappear, and 
only become evident in moments of repose. 

Hypertrophy of the left ventricle. If this 
ventricle alone is enlarged, the symptoms 
just pointed out will be perceived only be- 
tween the fifth and seventh left sternal ribs, 
and investigation of the lower part of the 
sternum will make known the integrity of 
the right ventricle. 

Hypertrophy of the right ventricle. When 
this side is diseased, the contrary happens. 
The sound of the ventricular contractions is 
*12 



126 DISEASES OF THE HEART. 

dull, but it never becomes as much so as on 
the left side. 

The comparison of the two ventricles. 
which is always easily made, gives great fa- 
cility and certainty to the diagnosis in this 
disease. 

Art. II. — Disease characterized by aherc 

id. 

D '/. :•: /■::'■; ■;:- of the heart. There are the 
same alterations of the respiration as in hy- 
pertrophy, but in a less legree, and less sub- 
ject to paroxvsms. The soimd on percussion 
of the precordial region is sometimes a little 
ure : there is a sonorous noise on the 
contraction of the ventricles, in extent al- 
ways proportioned to the degree of dilata- 
tion : very little shock : such are the signs of 
dilatation. 

Th se rarely effects the two ven- 

tricles together : it is more common on the 
right than the left side. The place where 
the sonorous, clapping sound is heard with 
most force, indicates which ventricle is di 
bted 



DISEASES OF THE HEART. 127 

Sometimes one side of the heart is dilated, 
the other hypertrophied ; we then find signs 
of dilatation on one side, and of hypertrophy 
on the other ; and the place where each set 
of signs is met, makes known the seat of 
each affection. 

Art. III. — Diseases characterized by altera- 
tion of impulse and sound. 

Dilatation with Hypertrophy. The signs 
of this affection are a combination of those 
of hypertrophy and those of dilatation. 

The contractions of the ventricles cause at 
once a strong impulse, and a distinct sound : 
those of the auricles are sonorous ; the pul- 
sations spread over a great extent, and in 
thin persons and children the impulse is evi- 
dent over almost the whole chest. This is 
the complaint, in which the contractions are 
easily felt by the hand, and produce an evi- 
dent palpitation, discernible at some distance : 
the rhythm of the pulsations is rarely altered. 
It is in cases of dilatation with hypertrophy, 
also, that percussion causes an almost per 
fectly flat sound. 



128 DISEASES OF THE HEART. 

As in the other varieties, the place where 
these phenomena are observed, shows the 
part of the heart which is affected, if only 
one half of that organ is affected. 

Contraction of the orifices of the Heart. 
M. Laennec mentions the bellows blast, and 
the rasp sound, as signs of this contraction, 
whatever may be the cause which produces 
it. 

The first of these phenomena often exists, 
without any lesion of the orifices. I have 
not had sufficient opportunity of convincing 
myself of the proper value of the second. 

These sounds attend the contractions of 
that part of the heart where the orifice is 
narrowed ; thus in the narrowing of the valve, 
it attends the contraction of the auricle ; when 
one of the arterial orifices is contracted, the 
sound accompanies the systole of the ven- 
tricles. 

The alteration of the orifices usually brings 
on hypertrophy of the part of which it re- 
strains the action, and the signs of this are 
joined to the rasp sound, or the bellows blast. 

Softening of the heart. We may consider 
this to exist when the heart returns a sound 



DISEASES OF THE CHEST. 129 

equally moderate, dull, and obtuse in its two 
contractions, and communicates little or no 
impulse. If the noise caused by the heart's 
contractions, although loud, is rather flat, and 
loses the clapping character usually attending 
dilatation, the softening is attended with that 
state ; but if the sound of the contraction is 
so indistinct as to be almost no longer heard, 
it will be accompanied by hypertrophy. 

Sometimes, however, in attacks of palpita- 
tion, a softened hypertrophied heart may pro- 
duce brisk contractions, short, and like the 
blow of a hammer, but this effort is of short 
duration, and the organ very soon falls back 
into its habitual state. 

Art. IV. — Aneurism of the Aorta. 

This disease may sometimes be recognized 
by simple pulsations, felt at some part of the 
upper and anterior part of the breast, or along 
the vertebral column. 

These pulsations, which are always syn- 
chronous with the pulse, have often more force 
and sound than the ventricular contractions ; 
but those symptoms are most frequently ab- 
sent. 



130 DISEASES OF THE CHEST. 

Two months ago, a woman laboring under 
this disease was in the Neckar hospital, in 
whom the tumor distinctly projected at the 
right side and upper part of the sternum be- 
neath the first ribs. I examined her fre- 
quently, and could only observe the following 
phenomena : — The right ventricle yielded 
little impulse or sound ; the left communi- 
cated a very energetic shock ; its sound was 
dull : it was felt much more to the left than 
usual : I do not know whether this w r as natu- 
ral, or the effect of disease. On apply- 
ing the cylinder upon the sternum, a little 
above the heart, the contractions could be 
feebly heard, but not at all felt. Over the 
whole extent of the tumor they were heard 
double and tolerably loud, and a well marked 
impulse was besides felt at the moment of 
the contraction of the ventricles.* 

* On the use of the Stethoscope in Internal Aneurism. 

In aneurism examined by the stethoscope, there is a 
peculiar sound, different from that of the heart, and 
different also from that of the great arteries in their 
natural condition (which it may be difficult if not im- 
practicable to describe so as perfectly to convey the 
idea in words to one who has never observed the pecu- 



DISEASES OF THE CHEST. 131 



Art. V. — Pericarditis and Hydropericar- 
diwn. 

M. Laennec mentions the increased im- 
pulse and sound of the ventricular contrac- 

liarity upon the living body,) which is nevertheless 
characteristic of aneurismal dilatation. A person who 
has, in a single instance of well-marked aneurism, 
carefally investigated and observed the phenomena 
perceptible to the sense of hearing by means of the 
stethoscope, will readily recognize this peculiarity of 
the sound. This is not confined to aneurism of the 
large internal arteries, — the Editor of the present 
edition having observed it in inguinal, femoral, popli- 
teal, brachial aneurisms, as well as in those of the larger 
arteries within the chest and abdomen. In a case of 
varicose aneurism of the arm, produced by transfixing 
the vein and wounding the artery in bleeding, the 
sound produced, when examined by the stethoscope, 
might be compared to that of a circular saw acting 
upon wood, one small portion of the circle bearing in 
a less degree upon the wood than the remainder of the 
circle ; but the diminution of the sound scarcely 
amounting to a perfect intermission. 

The same sound, in a less degree, has been observed 
in varicose aneurism of the temporal artery, produced 
by the operation of cupping. 

In the discrimination of internal eneurism much 
may be ascertained by the physiological pathologist 



132 DISEASES OF THE CHEST. 

tions, with their inequality and dispropor- 
tion to the feebleness and smallness of the 
pulse, as signs of pericarditis. Perhaps the 
noise which I have compared to the creaking 
of leather, is a symptom of this affection ; it is 
one of short duration, limited to a few hours, 
if the disease is acute, and quickly produc- 
ing effusion ; more durable when the pro- 
gress is slower. The friction of the two 
lamina of the pericardium, deprived of the 
serious exhalation, by the inflammation, may 
explain the sound. 

This dryness seems to be the effect of in- 
flammation upon serous membranes. Thus, 
we observe it in coryza, upon the nasal mu- 
cous membrane ; in rheumatism, upon the 
synovial membranes ; and when the latter 
affection is chronic, and without effusion, 
w T e may produce the same kind of sound, in 

without the aid of the stethoscope ; but there are cases 
in which all the corroborative signs afforded by ordi- 
nary means of investigation amount only to a proba- 
ble conjecture of the aneurismal nature of the disease, 
in which the stethoscope, to the attentive and well- 
practised observer, affords evidence so unequivocal 
that it may almost be deemed demonstrative. — Ed. 



DISEASES OF THE CHEST. 133 

the knee for example, by rubbing the rotula 
upon the condyles. 

The severe pain seated in those parts, when 
the disease is acute, has hindered me from 
trying whether the same phenomenon exists 
at that time. But it is invariably true, that 
the symptoms of effusion into the sac are 
rarely observed on the first day. 

As to dropsy of the pericardium, the only 
symptoms which can lead us to suspect it, 
are a completely flat or fleshy sound in the / ' 
precordial region, and tumultuous and ob- 
scure pulsations of the heart, sensible in a 
great extent, and for some moments more at 
one point than at others, and reaching the 
hand, as if a soft body were interposed. 



EXPLANATION OF THE PLATES. 

PLATE I. 

The Plate represents a front view of the Viscera of the 
Thorax, the sternum and the anterior parts of the clavicles and ribs 
having- been removed. 

The chief points of demonstration are the following : 

Tlie sections of the ribs, which are marked numerically, the figure 1 
being placed on the uppermost rib. 

t marks the portions of the clavicles. 

RELATING TO THE LUNGS AND AIR PASSAGES. 

a, is placed upon the thyroid cartilage. 

b, The trachea, at the upper part of which, and immediately below 
the larynx, is seen the thyroid gland. 

c, d, e, The lobes of the tight lung. 

I The edges of the pleura may be seen surrounding the lungs and 

covering the upper portion of them. 
fi Si '^ ie l°b es °f the l e fi lung. 

The Heart is seen surrounded at its circumference by the edge of 
the divided pericardium t which at the upper part is seen crossing over 
the great vessels. 

The principal points relating to the heart and great vessels 

are, 
h, The vena cava descendens. 
i, The right auricle, 
k, The right ventricle. 
I, The pulmonary artery. 
+ The left auricle, a small portion only of which is seen between the 

root of the pulmonary artery, the pericardium, and the top of the 

left ventricle. 
m, The left ventricle. 

n, The ascending aorta, within the pericardium. 
o, The arch of the aorta, af:er it has emerged from the pericardium, 

crossing over and resting upon the trachea. 



EXPLANATION OF THE PLATES. 

Arising from the arch of the aorta are seen the three great trunks 
which supply the head, neck 7 and upper extremities : on the right, the 
arteria innominata, dividing into the right subclavian and the right 
carotid ; — on the left ; the left carotid and the left subclavian, arising sep- 
arately from the aorta. 

The contiguity of these great vessels to the air passages, renders a 
knowledge of their situation and relations of great importance to the 
pathologist. 

PLATE II. 
ILLUSTRATIONS OF THE STETHOSCOPE. 

The forms of the Instrument which have been approved, together 
with the proportions and dimensions of the different parts, are shown 
according to a scale. 

AAA, The top of the upper piece for applying to the ear. 
BBB, The lower end of the same piece hollowed out to receive the 

upper convex end of the second piece, and occasionally the stopper. 
CC, The upper end of the 2d piece rounded to fit the concavity of the 

end^. 
DD, The lower end of the same hollowed to receive the stopper. 
EE, The stopper made to fit the lower end of the other two pieces. 

A brass tube passes through it and projects beyond it ; to keep it 
more firmly in its place, when applied. 
FFFF, A canal perforating the whole length of the instrument. 

The upper piece may be used alone or with the stopper occasionally, 
the 2d piece being laid aside. 



PLATE III. 

This figure exhibits the effects of contraction of the chest consequent 
on pleurisy. 

a, The sound side. 

b, The contracted side. 



PLATE IV. 

A back view of the same subject. 



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